Use of the Femoral Vein as Insertion Site for

Tunneled Hemodialysis Catheters

Abigail Falk, MD

PURPOSE: To determine the outcome of tunneled hemodialysis catheters inserted through the common femoral vein.

MATERIALS AND METHODS: From April 2000 to June 2003, 33 consecutive patients had 86 tunneled hemodialysis
catheters inserted through the femoral vein. There were 14 male and 19 female patients with a mean age of 56 years.
Seventeen patients had bilateral central venous and/or superior vena cava (SVC) occlusions, 12 patients had unilateral
central venous occlusions and were to receive contralateral arteriovenous fistulas or arteriovenous polytetrafluoro-
ethylene grafts, and 4 patients received femoral catheters for other reasons. The technical success, complications, and
clinical outcomes of these procedures were retrospectively evaluated.

RESULTS: All procedures were technically successful. Fifty-seven catheters were inserted into the right femoral vein
and 29 into the left femoral vein. This included 25 catheter exchanges in 13 patients. Two patients developed thigh
hematomas. Follow-up data were available for 68 catheters; mean follow-up period was 51 days with a total of 3,484
catheter days. The catheter-related infection rate was 6.3 per 1,000 catheter days; 22 catheters were removed for
infection. Eighteen catheters were removed because of poor blood flows (<200 mL/min). Thirteen catheters were
removed because they had become retracted. Primary catheter patency was 44% at 1 month.

CONCLUSIONS: The femoral vein provides an alternative access site for insertion of tunneled hemodialysis catheters
when conventional sites are not available. However, tunneled femoral hemodialysis catheters have low primary
patency rates and significant complications. Catheter retraction is a unique and common problem.

J Vasc Interv Radiol 2007; 18:217–225

Abbreviations: DVT ⫽ deep venous thrombosis, IVC ⫽ inferior vena cava, NKF/KDOQI ⫽ National Kidney Foundation Dialysis Outcomes Quality Initiative
Clinical Practice Guidelines

THE preferred access site for a tun-
neled hemodialysis catheter is the
right internal jugular vein. Other ac-
cess sites include the right external
jugular vein, the left internal jugular
vein, and the left external jugular
vein. The subclavian veins should
only be considered when other op-
tions are not available. Furthermore,
tunneled cuffed catheters should not
From American Access Care, 200 Boston Avenue,
Medford, Massachusetts 02155. Received April 11,
2006; final revision received November 26, 2006;
accepted December 3, 2006. Address correspon-
dence to A.F.; E-mail: abigailfalk123@pol.net
The author has not identified a conflict of interest.
© SIR, 2007
DOI: 10.1016/j.jvir.2006.12.001
be placed on the same side as a ma-
turing arteriovenous fistula (1).
Hemodialysis access can be a chal-
lenging problem in patients who have
exhausted their access sites. When the
more common access sites are no
longer available, alternative access
sites become necessary. These sites
include the brachiocephalic veins,
translumbar, transrenal, and trans-
hepatic routes, and insertion of cath-
eters into collateral venous pathways
(2– 6).
When the usual routes are no
longer available and prior to the use of
other alternative access sites, we have
used the common femoral vein as our
preferred alternative access site for
tunneled hemodialysis catheters. The
purpose of this study was to deter-
mine the outcome of our experience
using the common femoral vein as a
venous access site for tunneled hemo-
dialysis catheters.
MATERIALS AND METHODS
Patients
A retrospective review of our inter-
ventional radiology database revealed
33 consecutive patients who under-
went insertion of a tunneled hemodi-
alysis catheter through the common
femoral vein between April 2000 and
June 2003. Fourteen male and 19 fe-
male patients with a mean age of 56
years (range, 29 –78 years) were in-
cluded in the study. Seventeen pa-
tients had bilateral central venous
and/or superior vena cava (SVC) oc-
clusions, 12 patients had unilateral
central venous occlusions and were to
receive a contralateral graft or fistula,

217
218 • Femoral Vein Insertion Site for Tunneled Hemodialysis Catheters
and 4 patients received femoral cathe-
ters for other reasons. This included
one patient who had recently under-
gone a surgical revision of a thoracic
aortic aneurysm who had chest wall
edema and excoriation, one patient
confined to a neck collar, one obese
patient on a ventilator, and one patient
with preexisting bilateral central lines
and a pacemaker.
Each patient’s vascular access his-
tory and radiologic studies were re-
viewed. Specific attention was paid to
the number and location of previous
catheters, grafts, and fistulas, the doc-
umentation of known central venous
disease, failed attempts at catheter
placement, and abdominal and pelvic
imaging. Follow-up data were ob-
tained from radiology records, the di-
alysis nursing staff, nephrologists, and
the dialysis research coordinator at
weekly interdisciplinary conferences
held in conjunction with the interven-
tional radiologists at our institution.
This information included the techni-
cal success, complications, and clinical
outcomes of all procedures.
Patients with infection did not have
tunneled catheters placed and were
therefore excluded from the study.
Two patients with a coagulopathy
had catheters placed once the coagu-
lopathy was corrected. Patients with
deep venous thrombosis (DVT) or a
history of DVT were not necessarily
excluded from the study if the femoral
vein was the only access site available
for catheter placement. Patients with
inferior vena cava (IVC) filters had
femoral catheters placed as needed.
Translumbar, transhepatic, and trans-
renal routes of catheter placement
were not attempted in these patients.
Institutional review board approval
was obtained for this retrospective
analysis.
Catheter Insertion Methods
All patients underwent sono-
graphic evaluation to determine the
patency of the jugular, subclavian,
brachiocephalic, collateral, and femo-
ral veins to determine the optimal ac-
cess site. All patients with central ve-
nous occlusions had attempts made to
cross those occlusions for catheter
placement before femoral venous ac-
cess would be considered (7). Right-
sided femoral venous access was con-
sidered to be preferable to left-sided
femoral venous access.
All procedures were performed in
the interventional radiology suite. Pa-
tients were sedated with intravenous
Versed (Midazolam, Hospira, Inc.,
Lake Forest, Ill) and fentanyl citrate at
the discretion of the interventionalist.
In accordance with the Centers for
Disease Control Guidelines for the
Prevention of Intravascular Catheter-
Related Infection, no oral or parenteral
antibacterial or antifungal drugs were ad-
ministered (8). The femoral vein was can-
nulated using a 21-gauge micropuncture
needle. Sonographic guidance was used if
difficult cannulation was anticipated, such
as in three obese patients or in one pa-
tient where the femoral artery could
not be easily palpated. A needle guide
was not used. An 0.035-in. extra-stiff
guide wire was inserted through the
coaxial dilator, which was then con-
verted to a 15-F peel-away introducer
sheath. A measuring wire was placed
through the sheath and used to guide
the selection of catheter length chosen.
A subcutaneous tunnel was created
from the venotomy site inferiorly to
the lateral thigh using a blunt-tip tun-
neling instrument. The catheter was
attached to the tunneler, pulled through
the tunnel, and inserted through the
sheath. Under fluoroscopic guidance,
the tip of the catheter was positioned
within the IVC above the confluence
of the iliac veins (Fig 1). The peel-
away sheath was then removed.
Bleeding at the venotomy site was
managed with manual compression.
Fluoroscopic images of the pelvis and
abdomen were obtained to assess
catheter tip position and to exclude
catheter kinking. If the proximal port
of the catheter was not open to the
lumen of the IVC, then the extra-stiff
guide wire was reinserted through the
distal port, and the catheter was with-
drawn several centimeters and rein-
serted while twisting, so that the tip
would be appropriately placed. The
catheter was secured to the patient
with sutures.
Catheter Management
Catheters with flow rates ⬍200
mL/min were initially managed with
the instillation of a thrombolytic agent
into both lumens of the catheter, as has
been described in previous studies
(9,10). If this treatment failed, the pa-
February 2007 JVIR
tient was referred to interventional ra-
diology for evaluation. Images were
obtained to evaluate tip position and
catheter kinking.
An imaging study was performed
by injection of contrast through the
proximal port to evaluate the presence
of a fibrin sheath and/or thrombus
formation once the catheter had been
freed from the tunnel and retracted to
the level of the external iliac vein. If a
fibrin sheath was identified, a super-
stiff hydrophilic guide wire was in-
serted through the proximal port and
the catheter was exchanged for a bal-
loon catheter. Several inflations were
performed using an 8- to 10-mm-di-
ameter angioplasty balloon to disrupt
the fibrin sheath. A new catheter was
then placed over the two guide wires,
and the tip was positioned within the
IVC. If thrombus was identified sur-
rounding the old catheter tip, the new
catheter was placed with its tip more
cranially in the IVC above the thrombus
and in the right atrium if necessary. The
patient received a coagulopathy work-
up, and long-term anticoagulation was
considered (Fig 2).
If a patient presented with lower
extremity edema after placement of
the femoral catheter, an evaluation for
DVT was performed. Patients were
anticoagulated as necessary. Catheters
were not removed unless other access
was established.
Patients with catheter-related bac-
teremia were treated with antibiot-
ics. Loading doses of 20 mg/kg van-
comycin and 2 mg/kg gentamicin
were given. This was followed by 1
mg/kg gentamicin intravenously af-
ter hemodialysis. Antibiotic selection
was adjusted as appropriate for the
blood culture species and sensitivity
results.
When the patient was afebrile and
blood cultures had been negative for
1 week, the catheter was exchanged
for a new tunneled hemodialysis
catheter, usually through the exist-
ing tunnel. Antibiotic therapy con-
tinued for 3 weeks from the date of
line change. Antibiotic therapy was
of longer duration if complications
such as endocarditis or osteomyelitis
were present.
Each catheter insertion and/or ex-
change was considered an indepen-
dent event.
All patients who received femoral
catheters were instructed not to have
Volume 18 Number 2
Figure 1. (a) Right femoral catheter with tip in perirenal IVC. Catheter tip must be within the IVC above the confluence of iliac veins.
Arterial lumen (arrowhead) faces medially, away from the IVC wall, into the lumen of the IVC. (b) Right femoral catheter, radiographic
view of venous insertion site (arrowhead) and tunnel (***).
their catheters removed unless inter-
ventional radiology was present and
plans for other access had been made.
Definitions
In accordance with the definitions
provided in the Society of Interven-
tional Radiology Reporting Standards
for Central Venous Access, the follow-
ing definitions were used (11).
Successful Catheterization.—Success
was defined as catheter introduction
into the venous system with the tip
positioned in the desired location,
and with adequate catheter function.
Adequate catheter function was indi-
cated by an ability to withdraw
blood for sampling or for infusing
saline into the device without signifi-
cant resistance.
Technical Success.—A procedure was
considered to be technically success-
ful upon completion of one hemodi-
alysis session with a flow of ⱖ300
mL/min.
Technical Failure.—A procedure was
considered to be a technical failure if
no single hemodialysis session with
flow rate ⱖ300 mL/min could be com-
pleted after catheter placement.
Early Complications.—These were de-
fined as complications occurring within
30 days of the procedure and catego-
rized as occurring either within the
first 24 hours after the procedure or
within 30 days of the procedure.
Late Complications.—These were de-
fined as complications occurring 30
days after the procedure. Long-term
complications such as catheter occlu-
sion and infection were reviewed.
Minor Complications.—These included
those complications in which no or nom-
inal therapy was required and there
were no consequences.
Major Complications.—These included
those complications that required ther-
apy, an unplanned increase in level of
care, a hospitalization, permanent ad-
verse sequelae, or death.
Catheter-related Infections.—These
were defined as growth of organisms
on the catheter tip and in the blood,
with no other source of infection,
and clinical signs and symptoms of
sepsis.
Exit-site Infection.—Erythema, tender-
ness, induration, and/or purulence
within 2 cm of the catheter exit site
in the absence of bacteremia.
Falk • 219
Tunnel Infection.—Erythema, tender-
ness, and/or induration along the sub-
cutaneous tract of a catheter more than
2 cm from the skin exit site.
Catheter Retraction.—Catheter retrac-
tion was defined as withdrawal of the
catheter so that the cuff was no longer
in the subcutaneous tunnel; however,
the catheter tip remained in the pa-
tient, commonly in the iliac veins, and
could still demonstrate aspiration and
flush. Catheters that presented as re-
tracted catheters were no longer se-
cured by the anchoring sutures but
were secured to the patient with an
abundant amount of adhesive tape.
Quantitative and Statistical Analysis
Calculations included the technical
success rate, the number of catheter
days (counted from the day of tun-
neled catheter insertion), the rate of
infection per catheter days, the num-
ber of procedure-related and non-pro-
cedure-related complications, and the
number of catheter removals.
The primary patency rate, also
known as primary device service in-
terval, is defined as the number of
catheter days from the time of catheter
220 • Femoral Vein Insertion Site for Tunneled Hemodialysis Catheters February 2007 JVIR

Figure 2. (a) Poorly functioning left femoral venous catheter due to thrombus (arrowheads) formation around catheter tip. Catheter
originally in the IVC, however, it became retracted with tip in the common iliac vein. Catheter failed infusions of lytic agent for catheter
clearance. (b) The catheter was exchanged over super-stiff Glidewire wires (Terumo Medical Corporation, Somerset, NJ) for a 55-cm
catheter, and the tip was positioned in the mid IVC above the thrombus. Patient was started on anticoagulation therapy.

placement until the removal at the
completion of therapy, patient death,
conclusion of the study with the cath-
eter still functioning or device failure
requiring catheter exchange, removal,
or the need for any additional inter-
vention by interventional radiology to
maintain patency (11). The secondary
patency rate, also known as the total
access site service interval, is defined
as the sum of all device service inter-
vals at a single access site. This ac-
counts for devices replaced or manip-
ulated due to device failure but
maintaining the original venous access
site. Replacement of an inadvertently
removed catheter through the existing
subcutaneous tunnel results in a new
device service interval but does not
end the access site service interval.
This secondary patency rate refers to
the ability to perform dialysis and ob-
tain adequate flow rates via that access
site, regardless of the need for catheter
exchange, administration of thrombo-
lytics, or other interventions to main-
tain the ability to dialyze through that
site (11). A Kaplan-Meier analysis was
performed to construct a life table es-
timate of catheter survival. Primary
and secondary patency rates at 30, 60,
90, and 180 days were recorded. All
initial 86 catheters were included in the
life table estimates of catheter survival.
Chi-square analysis was performed to
evaluate statistical significance between
right-sided and left-sided catheters.
RESULTS
A total of 86 tunneled hemodialysis
catheters were inserted through the fem-
oral vein in these 33 patients. This in-
cluded 25 femoral catheter exchanges that
were performed in 13 patients.
Fifty-seven catheters were inserted
into the right femoral vein and 29 into
the left femoral vein. This included
three patients who had catheterization
of both the right and left femoral veins
during the study period. Seven types
of hemodialysis catheters were used.
Catheter length varied from 19 cm to
80 cm (Table).
All procedures were technically
successful. All catheters were success-
ful in providing acceptable blood flow
(⬎300 mL/min) during the first hemo-
dialysis treatment.
Two patients had infrarenal IVC fil-
ters. In one patient, the catheter tip
was positioned below the IVC filter,
and in the other patient the catheter
was advanced through a thrombosed
IVC and the tip positioned into the
patent intrahepatic IVC.
In one patient, a catheter was
placed adjacent to nonobstructing
thrombus that was limited to the com-
mon femoral vein. The patient was
placed on anticoagulation and did not
have extension of the thrombus dur-
ing the study period.
Long-term Follow-up
Follow-up data was available for 68
catheters. The mean follow-up period
Volume 18 Number 2 Falk • 221

The Distribution of Catheter Types and Lengths That Were Used in the Study Patients
19 cm 23 cm 24 cm 27 cm 28 cm 31 cm 35 cm 36 cm 40 cm 45 cm 50 cm 55 cm 60 cm 80 cm Unknown
Opti-Flow 1 6 2 1 27
HemoGlide 1 1 1 1
More-Flow 1 4 1 8
Vaxcel 1 2
PermCath 1 1
Hickman 2 1 7 4 1
Tesio-Cath 3
Unknown 8

Note.—Opti-Flow (Bard Access Systems, Salt Lake City, Utah); HemoGlide (Bard Access Systems); More-Flow (AngioDynamics,
Inc., Queensbury, N.Y.); Vaxcel (Boston Scientific, Natick, Mass.); PermCath Quinton (Sherwood Medical, St. Louis, Miss.);
Hickman (Bard Access Systems); Tesio-Cath (Medcomp, Harleysville, Pa.).

was 51 days with a total of 3,484 cath-
eter days.
Twenty-two (32%) catheters were
removed for catheter-related infection,
yielding a catheter-related infection
rate of 6.3 per 1,000 catheter days. Eigh-
teen (27%) catheters were removed be-
cause of poor blood flow (⬍200 mL/
min). Contrast studies identified 13
fibrin sheaths (Fig 3) of which five
had associated pericatheter/perisheath
thrombus. Thirteen (19%) catheters
were removed because the cuff of the
catheter had retracted from the subcu-
taneous tunnel. Ten catheters had re-
tracted within 30 days after placement.
One of these catheters had been inad-
vertently retracted by the physician
house staff. The retracted catheters
were replaced with new femoral cath-
eters through the existing tunnel and
venotomy sites. Ten (15%) catheters
were removed when no longer
needed, including five patients with
new peritoneal dialysis, three patients
with working arteriovenous grafts,
and two patients with working arte-
riovenous fistulas. Four (5%) catheters
were functioning at the end of the
study period, and one (2%) patient
died of unrelated causes with a func-
tioning catheter.
There was no statistical significance
between right-sided and left-sided
catheters in overall rates of fibrin
sheath (␹2 ⫽ 2.12, P ⱕ .2). There was
no statistical significance between
right-sided and left-sided catheters in
overall rates of perisheath thrombus
(␹2 ⫽ 0.29, P ⱕ 1.0).
Patency Rates
Primary catheter patency at 30, 60,
90, and 180 days were 44%, 29%, 20%,
and 4%, respectively. Mean catheter
patency was 51 days; median catheter
patency was 25.5 days (range, 1–294
days). The mean number of interven-
tions to maintain access site function
until that access was no longer used
was two interventions, with a range of
1–13 interventions.
Secondary catheter patency at 30,
60, 90, and 180 days were 85%, 60%,
45%, and 25%, respectively (Fig 4).
Complications
There were two procedural-related
complications yielding an overall pro-
cedural complication rate of 2.3%.
Two patients developed thigh hema-
tomas; both occurred within 24 hours
after catheter placement. In both pa-
tients, this was a minor complication
that did not require additional therapy
or hospitalization.
Long-term complications included
two patients who developed right iliac
vein occlusion after use of the right
common femoral vein for catheter ac-
cess. These patients remained asymp-
tomatic, were not anticoagulated,
were not hospitalized, and the cathe-
ters were not removed.
One patient with a left-sided femo-
ral catheter developed a left common
femoral and iliac vein thrombosis that
extended into the IVC. The patient re-
mained asymptomatic and no inter-
vention was performed. This patient
was an inpatient at this time receiving
anticoagulation for a known coagu-
lopathy and therefore no additional
management or treatment was re-
quired. Another patient with a left-
sided catheter developed iliac com-
pression syndrome. This patient was
an inpatient at this time, anticoagula-
tion was initiated, and the patient con-
tinued hemodialysis through the left
femoral catheter.
There was no statistical significance
between right-sided and left-sided
catheters in the overall long-term com-
plication rate (␹2 ⫽ 0.87, P ⱕ 1.0).
DISCUSSION
Long-term hemodialysis access has
become a challenging problem in pa-
tients who have exhausted their access
sites. Patients who require chronic he-
modialysis are at risk for permanent
occlusion of the central veins (12). In
these patients, alternative access sites
must be sought. This problem is
heightened by the fact that tunneled
hemodialysis catheters are the least
desirable method of hemodialysis, but
there are a substantial number of pa-
tients who rely on catheters when
other means of dialysis (fistula, graft,
or peritoneal dialysis) are no longer
available to them (2– 6).
The femoral vein provides an alter-
native access site for insertion of a tun-
neled hemodialysis catheter when
conventional sites are not available
(13,14). Our technical success rate
(100%) for successful catheter inser-
tion is comparable with those of other
reports describing femoral tunneled
catheters (13,15).
Right-sided femoral catheters are
preferable to left-sided catheters for
several reasons. The anatomical course
through the right iliac veins into the
IVC is straighter and shorter than
through the left iliac veins. Placement
of a catheter through more tortuous
venous anatomy may increase the risk
of venous thrombosis. The left iliac
vein can be compressed by the overly-
222 • Femoral Vein Insertion Site for Tunneled Hemodialysis Catheters
Figure 3. Catheter has been retracted by the radiologist and contrast injected into the
iliac veins and IVC. Fibrin sheath (arrowheads) is seen as filling defect.
ing iliac artery (iliac compression syn-
drome), and this phenomenon may be
accentuated by placement of a large-
diameter hemodialysis catheter. Vari-
ant anatomy of the IVC, such as a du-
plicated IVC, could also prohibit left-
sided femoral catheter placement.
Although the differences noted in this
study between right-sided and left-
sided catheters were not statistically
significant, this study is limited by its
small sample size.
Femoral catheters have a higher re-
circulation rate when compared with
jugular and subclavian vein catheters
(16,17). The National Kidney Founda-
tion Dialysis Outcomes Quality Ini-
tiative Clinical Practice Guidelines
(NKF/KDOQI) for vascular access
states that femoral catheters should be
at least 19 cm long to minimize recir-
culation. In our study, the most com-
mon catheter length used was 35 cm
from tip to cuff (Table). Schwab re-
ported that when placing tunneled
catheters in the femoral vein, the ma-
jority of patients required a catheter
length of 45–50 cm for the catheter tip
February 2007 JVIR
to lay within the IVC (18). These inves-
tigators also reported that the use of
shorter-length catheters will often re-
sult in the catheter tip within the com-
mon iliac vein and are therefore more
prone to recirculation. However,
longer catheters may not be able to
provide high (⬎400 mL/min) blood
flow rates. Poiseuille’s law describes
the relationship between catheter
length and blood flow. As catheter
length increases, the rate of blood flow
decreases proportionally. Therefore,
blood flow through hemodialysis
catheters that are greater than 40 cm in
length often do not exceed 300 mL/
min. In addition, the longer catheters
have greater luminal volumes and re-
quire a larger amount of heparin solu-
tion after each catheter use.
In the current study, our femoral
catheter patency rates were lower than
those previously reported. Zaleski et
al reported 30-, 60-, and 180-day fem-
oral catheter primary patency rates of
78%, 71%, and 55%, respectively, and
secondary patency rates of 95%, 83%,
and 61%, respectively (13). Maya and
Allon reported primary patency rates
at 30, 60, 90, and 180 days of 71%, 43%,
33%, and 14%, respectively, with a me-
dian primary patency rate of 59 days
(19). Chow et al reported a median
survival of 166 days for tunneled fem-
oral catheters (14), and Pervez et al
reported a mean catheter survival of
79 days (15). Tunneled femoral cathe-
ters were placed using nearly identical
techniques by all of these investiga-
tors, and the catheter lengths were also
similar. The difference in patency rates
may be attributed to the patient pop-
ulation. The patient population in our
study was an inner city, lower socio-
economic population with many co-
morbid conditions. Perhaps it is possi-
ble that the comorbidity factors of this
population influenced the catheter pa-
tency rates in our patients.
Twenty-two catheters (32%) were
removed for catheter-related bacter-
emia. All patients received antibiotics
and subsequently underwent a cathe-
ter exchange procedure, over a guide
wire, to salvage the existing access
site. Maya and Allon reported that 6
(22%) of the 27 femoral catheters
placed were removed for refractory in-
fection (19). Our catheter-related infec-
tion rate of 6.3 per 1,000 catheter days
is comparable with the value of 5.2
reported by Zaleski et al but slightly
Volume 18 Number 2
1.0
0.8
Proportion Remaining
0.6
0.4
0.2
0.0
0 30 60 90
Primary Patency in Days
a.
Figure 4. (a) Kaplan-Meier survival curve for primary patency (primary device service interval). The two dashed lines, above and
below the solid line, represent the 95% upper and lower confidence limits, respectively. (b) Kaplan-Meier survival curve for secondary
patency (total access site service interval). The two dashed lines, above and below the solid line, represent the 95% upper and lower
confidence limits, respectively.
higher than the catheter-related infec-
tion rate of 3.8 reported by Chow et al
and the catheter-related infection rate
of 3.2 reported by Pervez et al in their
studies of femoral tunneled dialysis
catheters (13–15). In comparison with
a review of catheter-related bacter-
emia from tunneled dialysis catheters
placed in the upper extremities, Saad
reported bacteremia rates of 2.2 to 5.5
per 1,000 catheter days (20). This is
lower than our reported rate for fem-
oral catheters. Therefore, it seems in-
tuitive that our higher infection rate
could be related to the location of cath-
eter placement. Additional studies are
warranted to further investigate this.
The NFK/KDOQI Guidelines rec-
ommend a catheter-related infection
rate of less than 10% at 3 months and
less than 50% at 1 year (1). In our
study, 25% of femoral catheters were
removed before 90 days for infection,
and 32% were removed before 1 year.
Eighteen (27%) catheters were re-
moved because of suboptimal blood
flows (⬍200 mL/min). This compares
favorably with other studies. Maya
and Allon found that 15 (56%) of the
27 femoral catheters placed were re-
moved for poor blood flow (19). In
our study, contrast studies identified
13 fibrin sheaths, of which 5 had asso-
ciated pericatheter/perisheath throm-
bus. These catheters were removed,
the fibrin sheaths were disrupted with
balloon angioplasty, and new cathe-
ters were placed with the tips above
1.0
0.8
Proportion Remaining
0.6
0.4
0.2
0.0
180
b.
any thrombus. Fibrin sheath formation
generally causes catheter dysfunction
weeks or months after catheter place-
ment. The incidence of fibrin sheath as
a cause of catheter dysfunction has
been reported to be 13%–57%, and our
results do not deviate from these val-
ues (21,22).
Ten (15%) catheters were removed
because of new access, five patients
initiated peritoneal dialysis and five
patients had an arteriovenous fistula
or arteriovenous graft successfully
placed. This does not compare as fa-
vorably with a study by Maya and
Allon, where 27 patients received tun-
neled femoral hemodialysis catheters
and 7 (26%) patients were able to con-
vert to a new permanent dialysis ac-
cess (19).
Catheter retraction was a unique
and common problem in our study
population. Thirteen (19%) femoral
catheters in six patients became re-
tracted necessitating replacement. One
patient presented five times with cath-
eter retraction but was managed with
a femoral catheter through the same
venotomy site for greater than 3 years.
The tunneled catheter becomes at-
tached to the tissue at the cuff. The
Dacron cuff attached to the catheter
and placed under the skin promotes
fibroblastic ingrowth of tissue into the
cuff, fixes the catheter in position, and
prevents bacterial migration around
the catheter. In a normal patient, it
takes approximately 3 weeks for the
Falk • 223
0 30 60 90 180
Secondary Patency in Days
cuff of the catheter to become incorpo-
rated into the surrounding tissues.
Wound healing is a complex process
encompassing a number of overlap-
ping events that include leukocyte re-
cruitment, matrix deposition, epitheli-
alization, and ultimately resolution of
inflammation with the formation of a
mature scar. Impaired wound healing
is seen in the elderly (23). Therefore, it
is assumed that in debilitated, elderly
patients it may take up to 1 month for
cuff incorporation and healing. Also,
corticosteroids suppress the inflam-
matory response to a variety of agents,
and they delay or slow healing (24). In
patients taking corticosteroid medica-
tions, it may take up to 6 – 8 weeks for
the incorporation of the catheter cuff.
It is possible that the incorporation of
the catheter cuff was delayed in our
elderly, debilitated patients and dur-
ing that time their catheters were at a
higher risk for retraction. In addition,
our study patients with tunneled fem-
oral catheters were allowed to ambu-
late within 2 hours after the catheter
insertion procedure. Because these
femoral catheters are placed across the
hip joint, this may contribute to cath-
eter retraction when the patient walks.
Ambulation may cause a back-and-
forth movement of the catheter within
the tunnel. This motion may also in-
hibit incorporation of the cuff into the
surrounding tissue. Other possibilities
for a high retraction rate include indo-
lent infections, which delay incorpora-
224 • Femoral Vein Insertion Site for Tunneled Hemodialysis Catheters
tion of the catheter cuff, as had been
implied in other studies (25).
A variety of complications can oc-
cur at the time of catheter placement.
Complications related to jugular, sub-
clavian, and brachiocephalic venous
punctures, such as arrhythmias, pneu-
mothorax, hemothorax, hemomedias-
tinum, laryngeal nerve injury, atrial
perforation, and thoracic duct injury,
are not associated with femoral vein
catheters (18). Only two minor proce-
dural-related complications occurred
in our study patients, and both were
managed conservatively.
The relationship between central
venous catheters and the long-term
complications of central venous dis-
ease including stenosis and occlusion
has long been recognized. Previously
published reports have shown that the
incidence of stenosis after catheter in-
sertion range from 20% to 50% for the
subclavian veins and up to 10% in the
internal jugular veins (26 –28). Risk
factors for stenosis are previous cath-
eter-related sepsis, increased cannula-
tions of the vein, and more cumulative
days of cannulation per vein (26,
27,29). Hegarty et al report one in-
stance of iliac vein stenosis after fem-
oral catheter placement (30). In our
study, two patients with right-sided
femoral venous catheters were found
to have right iliac vein occlusions.
Both patients remained asymptomatic,
and access across the occluded veins
was maintained throughout the study.
The lack of alternative venous access
sites represents a relative contraindi-
cation to catheter removal, and sub-
stantial efforts should be employed to
maintain these catheters.
The presence of a catheter within a
central vein can incite thrombosis of
that vein, and it is well-known that the
use of femoral lines increases the risk
of ileofemoral DVT (31,32). Two study
patients developed left iliac vein
thrombosis due to catheter placement.
Only one patient was symptomatic,
and both patients were conservatively
managed with anticoagulation ther-
apy. The catheters were not removed
until they were no longer needed. Ve-
nous thrombosis is often based on the
clinical presentation of the patient; ip-
silateral swelling of the extremity with
possible pain and tenderness. The di-
agnosis is often confirmed with ultra-
sound, venography, or other radio-
logic imaging studies. Traditional
February 2007 JVIR
Figure 5. Patient with bilateral central venous occlusions and a left common femoral
vein occlusion being managed with right femoral tunneled catheter. This was the patient’s
only access site. Patient was seen in an emergency room for an unrelated cause. Catheter
removal was attempted because it was mistaken for a temporary catheter. Femoral
catheters are not commonly tunneled, and therefore communication with and education
of other health care professionals as well as the patient is mandatory when placing these
catheters.
treatment consists of catheter removal spective design and relatively short
and anticoagulation. However, in pa- follow-up period. As a result, the long-
tients who have limited vascular ac- term risks of stenosis, thrombosis, and
cess sites, it may not be a wise decision infection may not have been ade-
to remove the catheter. These patients quately determined. Available data
may be best managed with anticoagu- did not allow for multivariate analysis
lation or, if necessary, intravenous of confounding specific risk factors
thrombolytic therapy. Others have en- such as age, ethnicity, and so forth. As
dorsed this practice. Maya and Allon well, the study did not address the
reported that 7 of the 27 patients who difference of the outcomes among dif-
received a tunneled hemodialysis cath- ferent brands and sizes of catheters.
eter developed DVT of the ipsilateral Further limitations include the ab-
lower extremity. All presented with uni- sence of comparison with other alter-
lateral lower-extremity edema, and the native venous access sites. Thus, fur-
diagnosis was confirmed by ultrasonog- ther research is warranted to help
raphy. Because of the absence of other determine which alternative access
options for other vascular access, all pa- sites are preferable in patients with
tients were treated with anticoagulation limited access.
therapy, and dialysis was continued In conclusion, a review of our expe-
through the existing femoral catheter rience with tunneled femoral hemodi-
(19). alysis catheters revealed low primary
Typically, femoral venous catheters patency rates and significant compli-
that are placed by health care profes- cations. In 78% of our study patients,
sionals are not tunneled. Therefore, if the femoral catheters were removed
interventional radiologists are going for infection, poor flow rates, or retrac-
to place tunneled femoral venous cath- tion. Despite this bleak picture, the use
eters, it is imperative that other health of the femoral vein as an insertion site
care professionals interacting with the for tunneled hemodialysis catheters
patient be informed and educated remains acceptable in those patients
about these catheters. If this is not who have no other options for long-
done, then the patient may be at risk if term hemodialysis.
someone who does not recognize that
the femoral catheter is tunneled at- Acknowledgment: The author would
tempts removal (Fig 5). like to thank Tom Vesely, MD, for his as-
This study is limited by its retro- sistance in preparation of this manuscript.
Volume 18 Number 2
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