General Description

The most common approach for vascular access used for diagnostic cerebral venography and neuroendovascular venous interventions is the common femoral vein (CFV). It is essential that the neurointerventionist understands the anatomy of the femoral vein and the anatomic structures related to it to minimize complications during vascular access.

Indications

Femoral vein access is indicated for any diagnostic cerebral venogram. The most common clinical indications include arteriovenous malformation or dural arteriovenous fistula venous embolization, inferior petrosal sinus sampling, venous sinus pressure monitoring, venous sinus thrombosis intervention, and venous sinus stenting.

Neuroendovascular Anatomy

The CFV is a continuation of the external iliac vein; this transition is anatomically marked by the inguinal ligament that extends from the bony anterior superior iliac spine to the pubic tubercle. The CFV extends from the inguinal ligament, and crosses at the medial third of the femoral head. At the junction of the femoral neck and lesser trochanter, the CFV bifurcates into the superficial femoral vein and profunda femoral vein. Small branches from the external iliac vein, such as the circumflex iliac and deep epigastric, are important to recognize to avoid placement of the access sheath within one of these small branches, resulting in vessel rupture and retroperitoneal hematoma. The CFV lies medial to the common femoral artery (CFA) and can be located by palpating the pulse of the artery and puncturing medial to the artery. It is important to note that the CFV communicates with the inferior vena cava on the right side of the spinal column, which in turn communicates with the superior vena cava and right and left brachiocephalic veins.

Specific Technique and Key Steps

It is important to obtain the patient’s history of previous arterial or venous femoral access, femoral bypass, stent placement, or any surgery at the inguinal region. A complete examination of the groin area with documentation of the femoral, popliteal, and pedal pulses is essential. For maximal efficiency, we routinely use the right femoral vein, unless there is a contraindication (e.g., scars from previous surgery, lack of a femoral pulse, multiple previous punctures/closure device placement, pseudoaneurysm, fistula formation, or history of lower-extremity deep vein thrombosis) ( Fig. 2.1 and Video 2.1 ).

1. 
   

   After the groin is prepared and draped, the site of the puncture is found by using bony landmarks. Then the site is confirmed radiographically with an X-ray. The anterior superior iliac spine and the pubic symphysis are connected by the inguinal ligament that marks the superior border of the CFV. This can be palpated in most individuals ( Fig. 2.1 and Video 2.1 ).

   
   
2. 
   

   The CFV runs medial to the CFA. This site is found under X-ray using a hemostat and it is marked. The lower third of the femoral head is the ideal site for vessel puncture because the vein is compressible here. The CFV is located 2 cm medial and caudal to the CFA pulse. Ultrasound imaging is useful for identification of the CFV and CFA.

   
   
3. 
   

   The skin and subcutaneous tissue over the CFV is infiltrated with an anesthetic agent. A single-wall puncture of the CFV is performed with a microneedle (21-gauge micropuncture kit) in a 45° angle with the bevel facing up.

   
   
4. 
   

   When nonpulsatile dark red blood is encountered, a (0.010 Cope Mandril, Cook Medical) microwire is advanced through the needle. If resistance is noted, stop! Confirm the microwire trajectory with an X-ray. The wire should go up and to the patient’s right side toward the iliac vein and inferior vena cava, avoiding the small lateral side branches. The needle is removed and an intermediate dilator (4–5F microsheath) is inserted. The introducer is removed and a J-wire is inserted. The microsheath is exchanged for a 4–6F sheath. For a diagnostic cerebral venogram, we prefer a 5F sheath. We prefer longer femoral sheaths (> 25 cm) for obese patients or patients with very tortuous anatomy. For intervention, we consider 80-cm Cook Shuttle sheaths (Cook Medical).

   
   
5. 
   

   After venous access has been established, we routinely perform a femoral venogram before proceeding with the case. We assess for CFV patency, stenosis, dissection, and possible extravasation ( Video 2.1 ). We do not use a closure device for venous punctures, and manual pressure is utilized for hemostasis.