Overview
Definition:
Femoral arterial line cutdown is a surgical technique to surgically expose and cannulate the common femoral artery, typically when percutaneous cannulation fails or is not feasible
It involves a small incision over the palpable femoral artery pulse to gain direct access for arterial line insertion, enabling continuous hemodynamic monitoring.
Epidemiology:
While percutaneous arterial cannulation is preferred, cutdown may be required in approximately 5-10% of cases, particularly in patients with previous groin surgeries, obesity, or difficult anatomy
The common femoral artery is the most frequently accessed site for arterial lines due to its large size and superficial location.
Clinical Significance:
Accurate and continuous hemodynamic monitoring is crucial for managing critically ill patients, including those in shock, undergoing major surgery, or requiring mechanical ventilation
Femoral arterial lines provide real-time data on blood pressure, enabling timely interventions to optimize perfusion and organ function
The cutdown technique ensures successful arterial access when less invasive methods are unsuccessful, thereby preventing delays in critical patient management.
Indications
Absolute Indications:
Failure of percutaneous femoral arterial cannulation after multiple attempts
Need for prolonged arterial access in emergent situations where percutaneous access is impossible
Situations requiring precise vascular control, such as during certain vascular reconstructive procedures.
Relative Indications:
Obesity with difficult palpable pulses
Previous groin surgery or radiation therapy to the groin
Significant coagulopathy where blind percutaneous puncture carries a higher risk of hematoma
Patients with anatomical variations affecting percutaneous access.
Contraindications:
Known significant infection at the puncture site
Absence of palpable femoral pulse (relative)
Severe peripheral vascular disease affecting the femoral artery
Anticoagulation that cannot be temporarily reversed (relative, weigh risks vs benefits)
Local malignancy involving the femoral artery.
Preoperative Preparation
Patient Assessment:
Thorough assessment of the patient's hemodynamic status, coagulation profile (PT/INR, aPTT, platelet count), and previous medical/surgical history
Identification of allergies, especially to local anesthetics and antiseptic solutions.
Site Selection:
Palpation of the common femoral artery pulsation, typically inferior to the inguinal ligament and medial to the anterior superior iliac spine
The optimal site is where the pulse is strongest
Ultrasound guidance can enhance accuracy in identifying the artery and avoiding nearby structures.
Equipment Gathering:
Sterile drapes, gown, gloves, masks, and eye protection
Local anesthetic (e.g., lidocaine 1-2%)
Antiseptic solution (e.g., chlorhexidine or povidone-iodine)
Scalpel (e.g., #11 blade)
Fine dissecting forceps and hemostatic forceps
Suture materials (e.g., 4-0 or 5-0 non-absorbable for vessel ligation, 3-0 absorbable for skin closure)
Arterial line kit (including catheter, introducer sheath, transducer tubing)
Heparinized saline for flushing.
Anesthesia And Asepsis:
Administer local anesthetic to the skin and subcutaneous tissue overlying the anticipated incision
Prepare the skin with an antiseptic solution and allow it to dry
Maintain strict aseptic technique throughout the procedure.
Procedure Steps
Incision And Dissection:
Make a transverse or longitudinal incision, approximately 2-3 cm in length, directly over the strongest palpable pulse of the common femoral artery
Carefully dissect through the subcutaneous tissue down to the adventitia of the artery, using fine dissecting instruments to avoid damaging the vessel wall.
Arterial Identification And Mobilization:
Once the artery is identified, gently mobilize it using a blunt dissector or forceps
Small, fine sutures (e.g., 4-0 silk or proline) can be passed proximally and distally to control the vessel temporarily if needed, or ligated if the artery is transected inadvertently.
Arteriotomy And Cannulation:
Create a small arteriotomy using a #11 scalpel blade
The size of the arteriotomy should be appropriate for the arterial catheter being inserted
Insert the arterial catheter through the arteriotomy, advancing it into the lumen of the artery
Heparinized saline flush should be initiated immediately upon insertion.
Securing The Line:
Secure the arterial catheter firmly in place using a securement device or sutures to the adventitia and/or skin to prevent dislodgement
Ensure there is no pulsatile bleeding around the insertion site
If temporary control sutures were used, release them once the catheter is secure
Close the skin incision with interrupted sutures.
Connection And Flushing:
Connect the arterial catheter to the transducer tubing system filled with heparinized saline
Ensure all air bubbles are removed from the system
Flush the line to confirm patency and adequate flow
Verify waveform and blood pressure readings.
Postoperative Care
Monitoring Requirements:
Continuous monitoring of arterial pressure waveform and numerical values
Regular checks for signs of distal ischemia, such as coolness, pallor, loss of pulses, or paresthesia in the affected limb
Monitor the insertion site for bleeding, hematoma, or signs of infection.
Anticoagulation Protocol:
Arterial lines are typically flushed with heparinized saline to prevent thrombosis
In select cases, systemic anticoagulation may be considered, but this requires careful consideration of the bleeding risk
Consult institutional protocols for anticoagulation management with arterial lines.
Line Maintenance:
Regularly check the integrity of the line and connections
Ensure continuous flushing to maintain patency
Rotate the arterial catheter if clinically indicated and per institutional policy to minimize risk of infection and thrombosis.
Complication Surveillance:
Vigilant monitoring for early and late complications
Promptly address any signs of infection, ischemia, bleeding, or thrombus formation
Educate nursing staff on recognizing and reporting potential issues.
Complications
Early Complications:
Hemorrhage or hematoma formation at the insertion site
Accidental arterial transection or injury
Air embolism
Transient distal ischemia
Thrombosis of the artery
Nerve injury.
Late Complications:
Infection at the insertion site leading to arteritis or sepsis
Pseudoaneurysm formation
Arteriovenous fistula formation
Distal embolization of thrombus
Stenosis or occlusion of the femoral artery
Compartment syndrome.
Prevention Strategies:
Meticulous aseptic technique during insertion
Careful dissection to avoid vessel injury
Adequate securement of the catheter
Appropriate flushing with heparinized saline
Prompt removal of the line when no longer indicated
Ultrasound guidance for identification
Judicious use of local anesthetics to minimize systemic absorption.
Key Points
Exam Focus:
Indications for cutdown versus percutaneous access
Anatomical landmarks for femoral artery
Steps of the procedure and potential complications
Management of bleeding and infection
Importance of sterile technique.
Clinical Pearls:
Always palpate the pulse before making an incision
Use a small, controlled arteriotomy
Secure the line very well to prevent dislodgement
Consider ultrasound guidance for difficult anatomy
Educate the patient about the procedure and potential risks.
Common Mistakes:
Inadequate sterile precautions
Over-dissection leading to vessel damage
Making the arteriotomy too large, leading to difficulty in securement
Failure to adequately secure the line
Delay in removing the line when no longer indicated
Not recognizing signs of distal ischemia.