30 Hong Kong J Nephrol • April 2009 • Vol 11 • No 1

Brief Communication

Anatomical Anomalies of Femoral Vein are Not Observed in Indian Patients with Renal Failure: Ultrasound-based Study

Jai Prakash, Naveen Sharma, Rubina Vohra, Amit Dwivedi, Raja Ramachandran, Rabindra Nath Mishra, Om Prakash Sharma

Background: Femoral vein catheterization is the easiest and safest method for obtaining temporary vascular access in hemodialysis patients. We studied the structure and anatomical variation of femoral veins in uremic patients using ultrasound imaging.Methods: Ultrasonography of femoral vessels was carried out bilaterally in patients with acute renal failure (ARF) and chronic renal failure (CRF). The relationship between ultrasonographic measurements of femoral vessels and anthropometric data were evaluated using Pearson’s method.Results: A total of 157 patients (67 ARF, 90 CRF) were included in the study. The majority of the patients were male (68.8%), and mean age was 43.29 ± 16.74 years. Mean height, weight, and body mass index were 163.94 ± 8.53 cm, 61.96 ± 12.37 kg, and 22.99 ± 3.68 kg/m2, respectively. Mean depth of the femoral artery was 10.74 ± 4.74 mm on the left side and 9.92 ± 3.98 mm on the right side. Mean diameter of the femoral artery was 7.77 ± 1.57 mm on the left side and 7.64 ± 1.45 mm on the right side. Mean distance of the femoral vein from the skin surface was 13.68 ± 4.98 mm on the left side and 12.76 ± 4.85 mm on the right side. Mean diameter of the femoral vein was 9.47 ± 2.15 mm on the left side and 9.37 ± 2.25 mm on the right side. The femoral vein had adequate diameter (≥ 5 mm) on both sides in all patients. Abnormal location of the femoral vein was not observed in our study. The depth of femoral vasculature was deeper in overweight and obese patients compared to normal weight patients. Femoral artery puncture, multiple attempts before successful catheterization, and hematoma formation were observed in 11.0%, 13.5%, and 5.4% of patients, respectively.Conclusion: Anatomical variation and location anomalies of the femoral vein were not observed in Indian uremic patients. Femoral vein diameter was adequate (≥ 5 mm) in all patients bilaterally. However, there was a slight variation in depth (> 1 mm) and diameter (0.1 mm) of femoral vasculature between the left and right sides (left > right). [Hong Kong J Nephrol 2009;11(1):30–4]

Key words: femoral vein, hemodialysis, imaging technique, renal failure, vascular access

Department of Nephrology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India.Correspondence to: Dr. Jai Prakash, Professor & Head, Department of Nephrology, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221005, India.Fax: (+91) 542-2367568; E-mail: jpojha555@hotmail.com

Hong Kong J Nephrol • April 2009 • Vol 11 • No 1 31

Femoral vein anomalies not seen in uremic patients

INTRODUCTION

Angioaccess is essential for the performance of hemo-dialysis. The correct placement of large-bore venous catheters plays an important role in the management of hemodialysis patients. Femoral vein catheterization is the easiest and safest method for obtaining temporary vascular access in hemodialysis patients [1,2], but the procedure can be complicated due to various reasons, one of them being anatomic variation of the vessels. The femoral vein has been used with success and low mor-bidity [3] as the site of choice for inserting cardiac catheters in infants and older children [4]. Imaging study prior to catheterization would reduce the number of complications, in the event of anatomic variations in femoral vasculature [5]. The femoral vein lies medial to the femoral artery at the inguinal ligament and from there down it assumes a posterior position, occasionally it is found anteriorly or laterally [6,7]. We intend to reveal the probability of occult anatomic variations of the femoral vein and the reliability of external mark-guided approach on creating a temporary femoral vein angioaccess in uremic patients for hemodialysis.

METHODS

Study cohortThe present cross-sectional study was conducted at the Department of Nephrology of the Institute of Medical Sciences of Banaras Hindu University in Varanasi, India, from August 2005 to April 2007. Patients with acute renal failure (ARF) or chronic renal failure (CRF), irre-spective of etiology, with or without prior history of femoral vein puncture were included in the study. A total of 157 patients (67 ARF, 90 CRF) underwent ultrasound evaluation of their femoral vein anatomy. The diagnosis of ARF and CRF was made using standard clinical criteria. All patients were subjected to detailed clinical evaluation including history and physical examination to determine the evidence, cause and severity of renal failure. Anthropometric measurements of weight, height and body mass index (BMI) were taken.

Ultrasound of the femoral veinThe same observer performed all ultrasonographic measurements. Before ultrasound study, patients were placed in the supine position, and the femoral artery was localized manually in the femoral triangle inferior to the

inguinal ligament. The palpation status (palpable or not palpable) of the femoral artery was recorded. Ultrasound examination was performed in this location using a 5–10-MHz linear array transducer (GE Logic 400; GE Healthcare, Milwaukee, WI, USA). The femoral vein was identified by lack of pulsatility, by compressibility with minimal pressure, and by an increase in vein lumen size induced by the Valsalva maneuver. The parameters measured at end-expiration included the distances be-tween the vessels, the luminal diameter of the vessels, and the depth of the vessels from the skin surface. Femoral veins were defined as adequate sized (≥ 5 mm) or small sized (< 5 mm) according to their diameter.

Statistical analysisData are expressed as range and mean ± standard devia-tion. The linear relationship of weight, height and BMI with ultrasonographic parameters were analyzed using Pearson’s method. Ultrasonographic measurements of femoral vasculature were compared with normal BMI versus BMI > 25 kg/m2 using Student’s t test.

RESULTS

A total of 157 patients with renal failure (108 males, 49 females) were included in the study, which took place from August 2005 to April 2007. Patient age ranged between 14 and 91 years, with a mean of 43.29 ± 16.74 years. BMI ranged between 13.8 and 31.3 kg/m2, with a mean of 22.99 ± 3.68 kg/m2. Sixty-seven (42.68%) patients had ARF and 90 (57.32%) had CRF. One hun-dred and twenty patients were evaluated before the initiation of hemodialysis therapy, while 37 were already receiving hemodialysis treatment. Eleven patients had a history of prior femoral vein catheterization. The femoral arteries were palpable normally and bilaterally in all 157 patients. The diameters of the femoral veins were adequate (> 5 mm) in all patients.

The ultrasound findings of the femoral vessels are shown in the Table. On the right side, the mean distance between the right femoral artery and the skin was 9.92 ± 3.98 mm, while that between the right femoral vein and the skin was 12.76 ± 4.85 mm. The mean diameter of the right femoral artery was 7.64 ± 1.45 mm, while that of the right femoral vein was 9.37 ± 2.25 mm. The mean distance between the right femoral artery and right femoral vein was 1.91 ± 0.54 mm. On the left side, the mean distance between the left femoral artery and the

J. Prakash, et al

32 Hong Kong J Nephrol • April 2009 • Vol 11 • No 1

skin was 10.74 ± 4.74 mm, while that between the left femoral vein and the skin was 13.68 ± 4.98 mm. The mean diameter of the left femoral artery was 7.77 ± 1.57 mm, while that of the left femoral vein was 9.47 ± 2.15 mm. The mean distance between the left femoral artery and left femoral vein was 1.93 ± 0.54 mm.

Of the patients already on hemodialysis, femoral artery puncture was observed in 10.81% (4/37). The femoral vein was successfully cannulated in 32 (86.48%) patients on the first attempt using external landmark-based technique. However, multiple puncture and sub-sequent successful cannulation on the second or third attempt took place in the remaining five (13.52%) patients. Femoral vein thrombosis was observed in one patient who had a history of previous femoral vein catheterization. The depth of femoral vessels was cor-related with body weight and BMI. Depth of the right femoral artery (p = 0.049 for BMI; p = 0.297 for weight) and right femoral vein (p = 0.035 for BMI; p = 0.111 for weight) was better correlated with BMI than with body weight. But correlation of the depth of the left femoral vein was better with body weight than with BMI (p = 0.79 for BMI; p = 0.030 for weight). However, depth of the left femoral artery did not show any significant correlation with body weight (p = 0.175) or BMI

(p = 0.340). The depths of the femoral vein on the right and left sides were positively correlated with BMI (Figures 1 and 2).

In summary, ultrasound evaluation of the femoral vessels in 157 patients with renal failure revealed that, in all patients, the femoral arteries were palpable, the femoral veins were located medial to the femoral arteries, and the femoral veins had adequate diameter (≥ 5 mm) on both sides. The depth of the femoral artery from the skin surface was deeper on the left side than on the right, and the depth and diameter of the femoral vein showed only very marginal differences between sides.

DISCUSSION

The external landmark-guided technique relies on the palpation of the femoral artery inferior to the inguinal ligament. The femoral vein is usually medial to this loca-tion and the puncture is done from this point [8–10]. The success of this approach also depends on a normal caliber and patency of the target vein and on veins being in their expected positions [10]. In a recent study, 57.26% (67) of patients were evaluated before and 42.73% (50) of patients were evaluated after dialysis

Table. Ultrasound findings of the femoral vessels (n = 157)*

Right side Left side

Distance between FA and skin (mm) 9.92 ± 3.98 (4.1–26.2) 10.74 ± 4.74 (4.1–30.0)Distance between FV and skin (mm) 12.76 ± 4.85 (3.2–33.2) 13.68 ± 4.98 (3.0–35.3)Diameter of FA (mm) 7.64 ± 1.45 (4.6–12.4) 7.77 ± 1.57 (4.3–12.2)Diameter of FV (mm) 9.37 ± 2.25 (5.4–17.1) 9.47 ± 2.15 (5.0–16.40)Distance between FA and FV (mm) 1.91 ± 0.54 (1.0–3.6) 1.93 ± 0.54 (1.0–4.2)

*Data presented as mean ± standard deviation (range). FA = femoral artery; FV = femoral vein.

y = 0.2212x + 7.6805R2 = 0.0283

0

5

10

15

20

25

30

35

BMI (kg/m2)

Dep

th o

f ri

ght f

emor

al v

ein

from

ski

n (m

m)

10 15 20 25 30 35

Figure 1. Scatter plot shows linear correlation and regression equation between body mass index (BMI) and depth of the right femoral vein from the skin surface.

Hong Kong J Nephrol • April 2009 • Vol 11 • No 1 33

Femoral vein anomalies not seen in uremic patients

[11]. But in our study, two thirds of the patients (76.44%) were evaluated before the initiation of hemodialysis. The difference in the percentages may be attributed to the lower socioeconomic status of our study cohort, who was less able to afford maintenance hemodialysis. The anthropometric measurements (mean height, weight and BMI) were also lower in our study compared to the reference study [11], and could be due to racial differ-ences and the nutritional status of the patients. In our study, 11 patients had a prior history of femoral cath-eterization, of whom two had bilateral catheterization. Nurhan Seyahi et al reported three patients with a history of prior femoral catheterization, of whom one had bilateral catheterization [11]. The difference is most probably due to the majority of our patients having CRF and receiving hemodialysis at other centers, because of the ease of cannulation of the femoral vein. Farrell and Gellens observed that 4.8% of femoral arteries were not palpable and this made it difficult to localize the femoral veins exactly using external landmarks [12]. In another study, 7.0% of femoral veins were difficult to cannulate because of their small size (< 5 mm), and this was espe-cially true with the generally used external landmark-guided technique [13]. Altogether, non-palpable femoral arteries or unsuitable femoral veins were found uni-laterally in 16 patients (14.0%) and bilaterally in six patients (5.2%) in Nurhan Seyahi et al’s study [11]. They also noted that 1.3% of the femoral veins were either not patent or absent, making placement of a femoral catheter impossible even with ultrasound guidance. Non-palpable femoral arteries were located deeper than palpable arteries. The most probable reason for such differences could be due to reduced BMI and malnutri-tion associated with renal failure in our patients [14]. The majority (93%) of our patients did not have prior

femoral vein cannulation and this may also explain the adequate size of their femoral veins (due to lack of venous wall sclerosis).

The depth of the femoral vessels from the skin sur-face was correlated with weight and BMI. In Nurhan Seyahi et al’s study, depth of the femoral artery and femoral vein were better correlated with BMI than with body weight bilaterally [11]. The present study showed a positive correlation between femoral artery diameter and body height (right side, p = 0.000; left side, p = 0.045). This finding was in concordance with the find-ings of Nurhan Seyahi et al [11], who also noted a positive correlation between femoral artery diameter and body height. However, we observed a positive cor-relation between the diameter of the femoral vein and BMI. We noted that the femoral arteries and veins were located further from the skin surface in patients with BMI > 25 kg/m2 compared to patients with normal BMI. This observation was similar to that of Nurhan Seyahi et al [11], who reported that the femoral arteries and veins were located significantly deeper in overweight patients (BMI > 25 kg/m2) than in normal weight patients. We also observed very slight differences between the depth and diameter of the femoral arteries and veins on the right and left sides. However, the depth and diameter of the femoral vessels and the distance between the femoral arteries and veins were similar on the right and left sides in Nurhan Seyahi et al’s study [11].

According to a recent review, ultrasound guidance reduced the relative risk of failed catheter placement by 71% in the femoral vein [15]. These findings are con-sistent with those of the reference study [11], in which 87.7% of the inspected veins were suitable for external landmark-based cannulation. Multiple punctures in-crease the rate of cannulation-related complications.

y = 0.1903x + 9.3137R2 = 0.0198

0

5

10

15

20

25

30

35

40

BMI (kg/m2)

Dep

th o

f le

ft f

emor

al v

ein

from

ski

n (m

m)

10 15 20 25 30 35

Figure 2. Scatter plot shows linear correlation and regression equation between body mass index (BMI) and depth of the left femoral vein from the skin surface.

J. Prakash, et al

34 Hong Kong J Nephrol • April 2009 • Vol 11 • No 1

The most frequent complications related to femoral vein cannulation are local hematoma formation and femoral artery puncture [10,12,16,17]. In our study, we observed that 10.81% of the patients had femoral artery puncture, which is comparable to the results of other studies (6.2–15.8% with the landmark-guided method and 0–7.1% with the ultrasound-guided method) [10,12]. We observed local hematoma in 5.4% of patients with the landmark-guided method. Local hematoma forma-tion was reported in 2.6% and 0% of patients with the landmark-guided and ultrasound-guided methods, re-spectively [12]. Femoral artery puncture can lead to arteriovenous fistula or pseudoaneurysm formation, but these complications are seldom reported [16]. Data on delayed complications are limited. Femoral vein throm-bosis was noted in one patient in our study who was on prolonged maintenance hemodialysis for ARF. In the reference study, only three of the 114 patients had a history of prior femoral catheterization, and thrombosis was detected in one of them [11]. Weyde et al evaluated 14 patients with previous prolonged (> 2 weeks) femoral catheterization and reported that femoral venous stenosis occurred in four cases [18]. Hughes et al examined the anatomic structures of femoral vessels in 50 non-uremic patients who were admitted to the intensive care unit [19]. They reported that the femoral artery overlapped the femoral vein in a significant number of subjects, especially where the vessels pass towards the apex of the femoral triangle. However, there was no com-plete overlap just below the inguinal ligament. Our results are in agreement with their work because we examined vessel anatomy only at the level of the inguinal ligament.

In conclusion, anatomic variation and location anomalies of the femoral veins are not observed in Indian uremic patients. The diameters of the femoral veins were adequate (≥ 5 mm) and the veins were located medial to the arteries in all of the patients. Moreover, the femoral veins tended to be located deeper in obese than in normal weight patients. Previous femoral vein catheterization carries a small risk of femoral vein thrombosis. Ultrasound-guided cannulation is preferred in obese patients and in patients with a previous history of catheterization.

REFERENCES

1. Mangiante EC, Hoots AV, Fabian TC. The percutaneous common femoral vein catheter in critically injured patients. J Trauma 1988;28:1644–9.

2. Swanson RS, Uhlig PN, Gross PL, McCabe CJ. Emergency intravenous access through the femoral vein. Ann Emerg Med 1984;13:244–7.

3. Kantner RK, Zimmerman JJ, Strauss RH, Stoeckel KA. Central venous catheter insertion by femoral vein: safety and effectiveness for the pediatric patient. Pediatrics 1986;77:842–7.

4. Carter GA, Girod DA, Hurwit RA. Percutaneous cardiac cathe-terization of the neonate. Pediatrics 1975;55:662–5.

5. Skolnick ML. The role of sonography in the placement and manage-ment of jugular and subclavian central venous catheters. AJR Am J Roentgenol 1994;163:291–5.

6. Snell RS. Clinical Anatomy for Medical Students. Philadelphia: Lippincott Williams & Wilkins, 2000:535–7, 613.

7. Anson BJ, McVay CB. Surgical Anatomy. Philadelphia: WB Saunders, 1971:1118.

8. Kaneda H, Kaneda F, Shimoyamada K, Sakai S, Takahashi M. Repeated femoral vein puncturing for maintenance haemodialysis vascular access. Nephrol Dial Transplant 2003;18:1631–8.

9. Lin BS, Kong CW, Tarng DC, Huang TP, Tang GJ. Anatomical variation of the internal jugular vein and its impact on temporary haemodialysis vascular access: an ultrasonographic survey in uraemic patients. Nephrol Dial Transplant 1998;13:134–8.

10. Kwon TH, Kim YL, Cho DK. Ultrasound-guided cannulation of the femoral vein for acute haemodialysis access. Nephrol Dial Transplant 1997;12:1009–12.

11. Seyahi N, Kahveci A, Altiparmak MR, Serdengecti K, Erek E. Ultrasound imaging findings of femoral veins in patients with renal failure and its impact on vascular access. Nephrol Dial Transplant 2005;20:1864–7.

12. Farrell J, Gellens M. Ultrasound-guided cannulation versus the landmark-guided technique for acute haemodialysis access. Nephrol Dial Transplant 1997;12:1234–7.

13. Gadallah MF, White R, Vickers B, el-Shahawy M, Work J. Aware-ness of internal jugular, subclavian, superior vena cava and femoral venous anomalies may reduce morbidity of acute venous catheter procedures. Clin Nephrol 1995;44:345–8.

14. Prakash J, Raja R, Mishra RN, Vohra R, Sharma N, Wani IA, et al. High prevalence of malnutrition and inflammation in undialyzed patients with chronic renal failure in developing countries: a single center experience from eastern India. Ren Fail 2007;29:811–6.

15. Hind D, Calvert N, McWilliams R, Davidson A, Paisley S, Beverley C, et al. Ultrasonic locating devices for central venous cannulation: meta-analysis. BMJ 2003;327:361.

16. Montagnac R, Bernard C, Guillaumie J, Hanhart P, Clavel P, Yazji J, et al. Indwelling silicone femoral catheters: experience of three haemodialysis centres. Nephrol Dial Transplant 1997;12:772–5.

17. Raja RM, Fernandes M, Kramer MS, Barber K, Rosenbaum JL. Comparison of subclavian vein with femoral vein catheterization for hemodialysis. Am J Kidney Dis 1983;2:474–6.

18. Weyde W, Badowski R, Krajewska M, Penar J, Moron K, Klinger M. Femoral and iliac vein stenoses after prolonged femoral vein catheter insertion. Nephrol Dial Transplant 2004;19:1618–21.

19. Hughes P, Scott C, Bodenham A. Ultrasonography of the femoral vessels in the groin: implications for vascular access. Anaesthesia 2000;55:1198–202.