Written by Chris Thom
Spoon Feed
In this meta-analysis of 12 studies across diverse clinical settings, ultrasound guided femoral artery access was associated with fewer complications, decreased number of attempts, and decreased vessel access time.
Don’t advance a needle without knowing where it’s heading
This was a meta-analysis incorporating 5534 patients, with 11 out of 12 included studies being RCTs. Most included studies involved comparison between US guidance and landmark guidance, with four studies being US guidance compared to fluoroscopic guidance. Outcomes included complication rates (hematoma and pseudoaneurysm formation), number of attempts, first-pass success, and time to successful vessel access.
The use of US was associated with a lower overall complication rate (OR 0.28, 95%CI 0.18-0.42). Time to successful vessel access was slightly shorter in the US group at -16.3 seconds (95%CI -29.8 to -2.76). The pooled OR of first-pass success was 3.84 for the US cohort (95%CI 3.25-4.55). Number of attempts was lower in the US cohort, but this did not reach statistical significance. Lastly, inadvertent venipuncture rate was lower in the US cohort with an odds ratio 0.21 (95%CI 0.14-0.30).
How does this change my practice?
While ultrasound guidance for internal jugular vein placement has long been standard practice, we often gravitate towards landmark approaches when performing subclavian and femoral vessel access. The evidence is mounting, however, that efficacy and safety is higher for US guidance of those access points as well. The current meta-analysis adds to the evidence that we should, whenever possible, use US for femoral arterial access as well. This makes sense, as one would intuit a benefit to actively watching the needle trajectory versus dealing with the variance in landmarks and relevant anatomy. Of course, we need to be effectively trained at “ultrasound guided needling” in order to succeed in this and other ultrasound guided procedures. The US guided IV remains the best “gateway drug” to becoming a wizard with ultrasound guided needling and those skills will translate to excellence in arterial access as well.
POCUS pro-tips:
The femoral artery can be found by placing the probe in the inguinal groin crease and scanning medially until you see the vessels. The artery is lateral, rounded, has a muscular wall that is often associated with calcification, and will be pulsatile with probe pressure applied. If you go too distal, you’ll invariably see the femoral artery wrap on top of the femoral vein. This is often the cause of an arterial stick during attempted femoral vein access. The artery can be fairly deep, so a steeper needle angle is sometimes necessary. Follow the needle tip in slow, purposeful advancements until entering the artery proper. If you lose track of where you are, simply fan towards the tip of the needle until you can again identify the tip of the needle.
Source
Ultrasound-guided vs. Non-ultrasound-guided femoral artery puncture techniques: a comprehensive systematic review and meta-analysis. Ultrasound J. 2025 Mar 6;17(1):19. doi: 10.1186/s13089-025-00422-8. PMID: 40048108
