UUCI Health · Department of Neurology
APP Class II · Procedural Competency Series · 2026
●  Procedure 04·Neurocritical Care·High-risk tier
04.

Arterial Line

Femoral.

Placement, management, and removal.
Chadwycke R. Smith, MSN, NP, AGACNP-BC
APP Education · Department of Neurology
Approving authority: Claire Henchcliffe, MD, DPhil · Chair, Department of Neurology
Version 2.0 · 2026-05-11
Source-of-truth: 01_Procedures/04_Arterial_Line_Femoral/
Arterial Line · Femoral · UCI Neurology APP Class II
01 / 21
UUCI · APP Class II
Procedure 04 · Arterial Line Femoral
02 · Why this matters

When radial fails — femoral wins.

Continuous invasive MAP · neurocritical care
  • Continuous invasive MAP is standard of care in aSAH with tight MAP targeting
  • Tight SBP targets in hypertensive ICH require beat-to-beat pressure
  • Post-arrest TTM with neuroprognostic MAP goals
  • Status epilepticus requiring hemodynamic support during induction
  • Failed radial access or radial perfusion inadequate in vasopressor-dependent shock
Why femoral, specifically
  • Large caliber — reliable cannulation when peripheral pulses are weak
  • Stability for transport in vasopressor-dependent shock
  • Accessible during airway management without competition for upper-extremity real estate
  • Complications are low frequency, high severity — retroperitoneal bleed, limb ischemia, pseudoaneurysm
Scheer B, Perel A, Pfeiffer UJ. Clinical review: complications and risk factors of peripheral arterial catheters. Crit Care. 2002;6(3):199–204 · PMID 12133178
Arterial Line Femoral · Why this matters
02 / 21
UUCI · APP Class II
Procedure 04 · Arterial Line Femoral
03 · Course objectives

What you'll leave with — six competencies.

01 · Cognitive

Femoral triangle anatomy.

Describe the NAVEL mnemonic lateral to medial — nerve, artery, vein, empty space, lymphatics — and recall why CFV sits medial to CFA at the inguinal ligament.

02 · Cognitive · Psychomotor

US discrimination.

Differentiate CFA from CFV on short-axis ultrasound: artery round, pulsatile, non-compressible; vein oval, compressible, thin-walled. Compressibility is the most reliable discriminator.

03 · Psychomotor

Seldinger cannulation.

Execute US-guided needle entry 1–2 cm caudal to inguinal ligament, pulsatile-return confirmation, wire-never-lost, catheter advancement, transducer setup.

04 · Cognitive

Square-wave test.

Interpret the fast-flush test — optimal, over-damped, under-damped — and justify remediation for each state. Level transducer to phlebostatic axis.

05 · Cognitive · Affective

Complication recognition.

Recognize retroperitoneal bleed, limb ischemia, pseudoaneurysm, AV fistula, CRBSI on clinical signs that mandate immediate escalation.

06 · Affective

Appropriate escalation.

Escalate to neurointensivist, vascular surgery, or interventional radiology on defined clinical triggers — without attempting unilateral resolution.

Arterial Line Femoral · Course objectives
03 / 21
UUCI · APP Class II
Section I of IV
I.
Section one

Anatomy & site selection.

Femoral is not interchangeable with radial. Lateral artery, medial vein, NAVEL from lateral to medial. Below the inguinal ligament — that's where we work. Know the anatomy before you pick up the probe.
Objectives C-1 · C-2 · C-3 · C-4 — slides 5–7
Arterial Line Femoral · Section I
04 / 21
UUCI · APP Class II
Procedure 04 · Arterial Line Femoral
04 · Femoral triangle

NAVEL — lateral to medial.

Femoral triangle borders diagram
Femoral triangle borders — inguinal ligament superior, sartorius lateral, adductor longus medial.
Daniel G. Bates · WikimediaCC BY-SA 3.0
  • N
    Femoral nerve. Most lateral. Outside the femoral sheath — not our target, but anatomic landmark.
  • A
    Common femoral artery. Target vessel. Round, pulsatile, thick-walled, non-compressible.
  • V
    Common femoral vein. Medial to artery. Oval, compressible, thin-walled.
  • E
    Empty space (femoral canal). Loose connective tissue · lymph node of Cloquet.
  • L
    Lymphatics. Most medial. Empty into deep inguinal nodes.
Standring S, Tubbs SR (eds). Gray's Anatomy: The Anatomical Basis of Clinical Practice. 43rd ed. Elsevier; 2025.
Arterial Line Femoral · NAVEL
05 / 21
UUCI · APP Class II
Procedure 04 · Arterial Line Femoral
05 · Short-axis discrimination

CFA lateral. CFV medial. Compressibility settles it.

Common femoral artery and vessels in the subsartorial canal
Common femoral artery (lateral) and vein (medial) at the inguinal ligament level.
Mikael Häggström · BruceBlaus deriv.CC BY-SA 3.0
FindingCFACFV
ShapeRoundOval
WallThick · hyperechoicThin
PulsatilityPulsatileNon-pulsatile
CompressibilityNon-compressibleCollapses
PositionLateralMedial
Compressibility is the most reliable discriminator — in shock, pulsatility may be diminished. Always compress before puncture.
Scheer B et al. Crit Care. 2002;6(3):199–204 · PMID 12133178
Arterial Line Femoral · Short-axis US
06 / 21
UUCI · APP Class II
Procedure 04 · Arterial Line Femoral
06 · Indications · contraindications

When to place — and when not to.

Indications
  • Severe hemodynamic instability requiring continuous MAP
  • Tight BP targets — aSAH, hypertensive ICH, post-arrest TTM
  • Frequent ABG sampling in respiratory failure
  • Failed radial access or radial perfusion inadequate
  • Vasopressor-dependent shock requiring transport stability
Scheer B et al. Crit Care. 2002;6(3):199–204 · PMID 12133178
Contraindications & thresholds
  • Absolute: active infection at the femoral access site
  • Absolute: ipsilateral vascular graft · recent ipsilateral vascular surgery
  • Absolute: critical ipsilateral PAD · ipsilateral DVT
  • Relative: severe coagulopathy not yet corrected · prior groin radiation · morbid obesity limiting US
  • Non-emergent thresholds: plt ≥ 50,000/µL · INR ≤ 1.5
  • Hold per ASRA-PM 5th ed (Kopp 2025) before non-emergent puncture
Kopp SL, Vandermeulen E, McBane RD, et al. ASRA-PM 5th ed regional anesthesia and pain medicine guidelines. Reg Anesth Pain Med. 2025 · PMID 39880411
Arterial Line Femoral · Indications & contraindications
07 / 21
UUCI · APP Class II
Procedure 04 · Arterial Line Femoral
07 · Pre-procedure · time-out

Before you puncture — the last gate.

  • 01
    Informed consent. Indication, risks (hematoma, retroperitoneal bleed, limb ischemia, infection, pseudoaneurysm, AV fistula), alternatives, right to refuse. Surrogate path when patient lacks capacity.
  • 02
    Labs verified. Platelets ≥ 50,000/µL · INR ≤ 1.5 for non-emergent placement. Anticoagulant / antiplatelet status reviewed against ASRA-PM holds.
  • 03
    US pre-scan completed. CFA position confirmed lateral to CFV. Patency verified. Depth from skin to anterior arterial wall noted.
  • 04
    Laterality marked. R or L femoral marked on skin. Communicated to bedside RN and any assistant.
  • 05
    Time-out called. Per TJC UP.01.03.01 — correct patient, procedure, side, equipment, consent confirmed aloud.
TJC standard

UP.01.03.01

Pre-procedure verification, site marking, formal time-out — the three-part protocol that exists because someone, somewhere, operated on the wrong side.
The Joint Commission. Universal Protocol UP.01.03.01.
TJC Hospital Accreditation Standards · 2024.
Arterial Line Femoral · Pre-procedure verification
08 / 21
UUCI · APP Class II
Key fact · UCI FPPE proctoring
UCI FPPE Master Plan §5 · April 2026
5 proctored cases
at the MED-HIGH risk tier — first three directly observed. Independent ratings on all five before privilege adds to your DOP.
Stream A
15-item post-test
≥ 12/15
Stream B
24-item skills
checklist
Stream C
Sim center
HIGH-risk gate
Live
5 proctored
Independent ratings
UCI FPPE Master Plan · The Joint Commission MS.08.01.01 · MS.06.01.05
09 / 21
UUCI · APP Class II
Procedure 04 · Arterial Line Femoral
08 · Kit · ultrasound pre-scan

What's on the table — before you puncture.

Kit checklist
  • Integrated a-line kit (needle, J-wire, catheter)
  • Pressurized saline flush transducer set
  • High-frequency linear US transducer
  • Sterile probe cover + sterile gel
  • Chlorhexidine-alcohol skin antiseptic
  • Full-barrier fenestrated sterile drape
  • Cap, mask with face shield, sterile gown, gloves
  • Suture or StatLock + transparent occlusive dressing
Pre-scan rules
  • Short-axis sweep of the femoral triangle
  • Confirm CFA lateral to CFV (NAVEL orientation)
  • Compressibility test — vein collapses, artery does not
  • Assess for variant anatomy or high bifurcation
  • Note depth from skin to anterior arterial wall
  • Mark optimal entry point on skin
Buetti N et al. SHEA/IDSA 2022 update · Infect Control Hosp Epidemiol. 2022;43(5):553–569 · PMID 35437133 · TJC IC.02.02.01
Arterial Line Femoral · Kit & ultrasound
10 / 21
UUCI · APP Class II
Section II of IV
II.
Section two

The cannulation
sequence.

Seven steps. Every step is a verification gate. Entry below the inguinal ligament. Pulsatile return. Wire-never-lost. Square-wave validated.
Objectives P-2 · P-3 · P-4 · P-5 · P-6 · P-7 · P-8 · C-7 · C-8 — slides 12–15
Arterial Line Femoral · Section II
11 / 21
UUCI · APP Class II
Procedure 04 · Arterial Line Femoral
09 · Steps 1–3

Prep, anesthetize, enter below the ligament.

01

Prep ·
full barrier.

  • Hand hygiene per WHO 5 Moments
  • Cap, mask + face shield, sterile gown, gloves
  • CHG-alcohol scrub, ≥30 s dry — do not blot, do not fan
  • Full-body fenestrated sterile drape
  • Sterile probe cover on linear US transducer
02

Local ·
1% lidocaine.

  • 1% lidocaine without epinephrine
  • Skin wheal at planned entry site
  • Infiltrate along anticipated needle track
  • Aspirate before each injection
  • Allow 60–90 s for onset
Femoral triangle schematic
Entry 1–2 cm caudal to the inguinal ligament, midpoint ASIS–pubic tubercle.
Craig Hacking · WikimediaCC BY-SA 4.0
03

Needle entry · below the inguinal ligament.

Landmark: 1–2 cm caudal to inguinal ligament, midpoint between ASIS and pubic tubercle, over medial third of femoral head. Patient supine, ipsilateral leg slightly abducted & externally rotated.
Trajectory: 30–45° under real-time US, short- or long-axis. Advance until tip confirmed in arterial lumen. High entry = retroperitoneal bleed risk. Low entry = bifurcation kinking risk.
Scheer B et al. Crit Care. 2002;6(3):199–204 · Buetti N et al. Infect Control Hosp Epidemiol. 2022;43(5):553–569 · PMID 35437133
Arterial Line Femoral · Steps 1–3
12 / 21
UUCI · APP Class II
Procedure 04 · Arterial Line Femoral · Critical checkpoint
Critical safety checkpoint · pulsatile return + wire-never-lost

Confirm pulsatile arterial return
before you advance the wire.

Method 01 · pulsatile flash

Bright red, brisk, pulsatile flow in the needle hub. Dark non-pulsatile = venous: STOP, withdraw, hold pressure 5 min, re-scan CFA before reattempt.

Method 02 · wire-never-lost

Operator maintains physical grip on the wire at all times. Resistance on advance → stop, reconfirm position, redirect bevel. Never force.

If wire won't advance
Force = wrong space or against vessel wall.
Reposition needle, reconfirm pulsatile return, retry.
Wire-never-lost is the foundational Seldinger discipline.
Scheer B et al. Crit Care. 2002;6(3):199–204 · PMID 12133178
Arterial Line Femoral · Critical checkpoint
13 / 21
UUCI · APP Class II
Procedure 04 · Arterial Line Femoral
10 · Steps 4–7

Wire, catheter, transducer, square-wave.

04

Wire ·
J-tip first.

  • J-tip first under operator control
  • Smooth advance — never force
  • Resistance → stop, reconfirm, redirect
  • WIRE-NEVER-LOST
05

Catheter ·
over wire.

  • Advance catheter into arterial lumen
  • Retrieve wire intact
  • Inspect for damage / deformation
  • Confirm pulsatile return from catheter hub
06

Transducer ·
phlebostatic.

  • Connect to primed pressure transducer
  • Pressurized flush ~3 mL/hr
  • Level to phlebostatic axis (4th ICS mid-axillary)
  • Zero to atmosphere · luer-lock all
07

Square-wave ·
read the damping.

  • Optimal: 1–2 brisk undershoot oscillations
  • Over-damped: slurred, blunted — air, kink, clot, loose
  • Under-damped: exaggerated, spuriously tall peaks
  • Diagnose damping before treating the number
Brzezinski M, Luisetti T, London MJ. Radial artery cannulation: anatomy and physiology review. Anesth Analg. 2009;109(6):1763–81 · PMID 19923502
Arterial Line Femoral · Steps 4–7
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UUCI · APP Class II
Procedure 04 · Arterial Line Femoral
11 · Secure · dress · order

Lock it down, then tell the chart.

Securement & dressing
  • Suture or manufacturer securement device (StatLock) at hub
  • Transparent occlusive dressing per Buetti 2022 SHEA update — site visible
  • Label dressing — date, time, initials
  • Confirm waveform stable on monitor before leaving bedside
Documentation set
  • Indication · consent · time-out · side
  • US use · # punctures · entry below inguinal ligament
  • Pulsatile confirmation · wire-advance under control
  • Catheter gauge / length · waveform status · square-wave
  • Complications · post-procedure orders
Post-procedure orders
  • Pressurized flush at ~3 mL/hr continuous
  • Limb checks q1h × 4h then per unit protocol — distal pulses, color, cap refill, sensation
  • Dressing check q shift — intact, dry, no bleeding
  • Waveform quality reassessed each shift
  • Removal criteria + hold parameters documented
Notify MD for
  • Damping change · weak distal pulse
  • Expanding groin mass · flank or back pain
  • Hemodynamic instability · hemoglobin drop
Removal: hold per ASRA-PM 5th ed (Kopp 2025) · manual pressure ≥10 min · monitor RP bleed signs ≥4 h.
Arterial Line Femoral · Securement & orders
15 / 21
UUCI · APP Class II
Section III of IV
III.
Section three

Recognize.
Escalate.

Femoral arterial complications are low-frequency, high-severity. The catastrophe is the delay — not the event. Diagnose on sight, escalate cleanly.
Objectives C-9 · A-3 · A-4 — slides 17–18
Arterial Line Femoral · Section III
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UUCI · APP Class II
Procedure 04 · Arterial Line Femoral
12 · Complications — recognize & escalate

Eight events you diagnose on sight.

01 · Severe

Retroperitoneal hemorrhage.

Flank/back pain, hypotension, Hgb drop, clean groin exam. CT angio · vascular surgery · hold anticoagulants · MTP if unstable.

02 · Vascular

Pseudoaneurysm.

Palpable thrill, expanding pulsatile mass. Confirm with US Doppler · vascular consult.

03 · Vascular

AV fistula.

New bruit at groin, machinery murmur. Confirm with US Doppler · vascular consult.

04 · Limb-threat

Distal limb ischemia.

Cold, mottled limb · weak DP/PT · cap refill >3 s. Remove line · vascular surgery emergent.

05 · Delayed

Catheter-related BSI.

CHG-alcohol prep, sterile barrier, daily necessity review. Same antiseptic discipline as CVL.

06 · Vascular

Local hematoma.

Expanding groin mass post-removal. Manual pressure ≥10 min · longer if anticoagulated.

07 · Vascular

Femoral thrombosis.

Higher with prolonged dwell. Daily review for necessity. Remove when no longer needed.

08 · Procedural

Wrong-vessel cannulation.

Dark, non-pulsatile return. STOP, withdraw, hold pressure 5 min, re-scan CFA before reattempt.

Cadaveric view of femoral vessels supporting retroperitoneal anatomy
Cadaveric femoral vessels — anchor for retroperitoneal / pseudoaneurysm anatomy.
John Campbell · WikimediaCC BY 2.0
Scheer B et al. Crit Care. 2002;6(3):199–204 · PMID 12133178
Kopp SL, Vandermeulen E, McBane RD, et al. Reg Anesth Pain Med. 2025 · PMID 39880411
Arterial Line Femoral · Complications
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UUCI · APP Class II
Procedure 04 · Arterial Line Femoral
13 · Pitfalls

Four errors we see — repeatedly.

01

Wrong vessel — venous puncture.

Dark, non-pulsatile return. STOP. Withdraw and hold pressure 5 min. Re-scan to confirm CFA before reattempt.

02

High puncture above the ligament.

Risks retroperitoneal hemorrhage. Stay 1–2 cm caudal to the inguinal ligament; midpoint ASIS–pubic tubercle on US.

03

Wire won't advance — force applied.

Force = wrong space or against vessel wall. Reposition needle, confirm pulsatile return, never push the wire.

04

Damped trace not investigated.

Square-wave test missed. Air, kink, clot, loose connection, low bag pressure, level off. Diagnose damping before treating the number.

Cadaveric femoral triangle dissection
Cadaveric femoral triangle — anchor for wrong-vessel / high-puncture failure modes.
Double-M (Athens GA) · WikimediaCC BY 2.0
Brzezinski M et al. Anesth Analg. 2009;109(6):1763–81 · PMID 19923502
Arterial Line Femoral · Pitfalls
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UUCI · APP Class II
Procedure 04 · Arterial Line Femoral
14 · UCI FPPE · OPPE

Your competency pathway.

StageTriggerScope
FPPEBoard approval of A-line Femoral privilegeFirst 5 independent cases · concurrent review within 14 d · aggregate at 5 cases · close within 6 mo
OPPEContinuous baseline · TJC MS.08.01.03Every 6 mo · 10% sample (min 2, max 10) · 100% review on complication flag
TriggeredSevere event · ≥2 failures in 90 d · safety report · M&MAd-hoc focused review per §3 structure · minimum 5 subsequent cases
Lapse< 3 lines over 24 mo rollingSim Stream C + 2 proctored live cases rated Independent
Tracked OPPE indicators
  • First-attempt success ≥ 80%
  • US-guided placement ≥ 95% overall · 100% in obesity / hypotension / weak pulse / failed radial
  • Limb complication rate target < 2%
  • Square-wave optimal at 24 h ≥ 90%
  • CRBSI rate target < 1 per 1,000 catheter-days
  • Documentation completeness 100%
High-risk tier Departures require written justification.
Arterial Line Femoral · FPPE / OPPE pathway
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UUCI · APP Class II
Procedure 04 · Arterial Line Femoral
15 · References & acknowledgments

Sources of truth.

  1. 01Scheer B, Perel A, Pfeiffer UJ. Clinical review: complications and risk factors of peripheral arterial catheters used for haemodynamic monitoring in anaesthesia and intensive care medicine. Crit Care. 2002;6(3):199–204. PMID 12133178.
  2. 02Brzezinski M, Luisetti T, London MJ. Radial artery cannulation: a comprehensive review of recent anatomic and physiologic investigations. Anesth Analg. 2009;109(6):1763–81. PMID 19923502.
  3. 03Kopp SL, Vandermeulen E, McBane RD, Perlas A, Leffert L, Horlocker T. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: ASRA-PM Evidence-Based Guidelines (5th ed). Reg Anesth Pain Med. 2025. PMID 39880411.
  4. 04Buetti N, Marschall J, Drees M, et al. Strategies to prevent central line-associated bloodstream infections in acute-care hospitals: 2022 update. Infect Control Hosp Epidemiol. 2022;43(5):553–569. SHEA/IDSA. PMID 35437133.
  5. 05Standring S, Tubbs SR (eds). Gray's Anatomy: The Anatomical Basis of Clinical Practice. 43rd ed. Elsevier; 2025.
  6. 06The Joint Commission. Universal Protocol UP.01.03.01. TJC Hospital Accreditation Standards; 2024.
  7. 06aThe Joint Commission. Universal Protocol UP.01.01.01 — preprocedure verification; use a standardized list (H&P, signed consent, nursing & preanesthesia assessment, labeled imaging, required equipment/devices). National Patient Safety Goals (HAP); effective January 2025.
  8. 06bThe Joint Commission. NPSG.01.01.01 EP 1 — use at least two patient identifiers (room number is not an identifier) before any treatment or procedure. National Patient Safety Goals (HAP); effective January 2025.
  9. 06cThe Joint Commission. NPSG.07.01.01 EP 1 — implement CDC and/or WHO hand-hygiene categories IA, IB, IC. National Patient Safety Goals (HAP); effective January 2025.
  10. 06dThe Joint Commission. Universal Protocol UP.01.02.01 — mark the procedure site; mark by the accountable licensed practitioner (APRN/PA delegation permitted per institutional policy); unambiguous, visible after prep & drape. National Patient Safety Goals (HAP); effective January 2025.
  11. 06eThe Joint Commission. NPSG.03.04.01 — label all medications, medication containers, and solutions on and off the sterile field (name, strength, amount, diluent, expiration). EP 4 requires two-individual verification when preparer ≠ administrator. National Patient Safety Goals (HAP); effective January 2025.
  12. 06fThe Joint Commission. NPSG.06.01.01 — clinical alarm safety; clinically appropriate settings, authority to change parameters, monitoring/response, and periodic accuracy checks for high-risk alarms. National Patient Safety Goals (HAP); effective January 2025.
  13. 06gThe Joint Commission. NPSG.02.03.01 EP 1 — report critical results of tests and diagnostic procedures within an established time frame; written procedures define which results are critical and to/from whom they are reported. National Patient Safety Goals (HAP); effective January 2025.
  14. 07The Joint Commission. Infection Prevention and Control. Standard IC.02.02.01; 2024.
  15. 08The Joint Commission. Human Resources. Standards HR.01.06.01 (initial competence) and HR.01.07.01 (ongoing competence, ≥3-yr cycle). 2024. (Per CITATION_AUDIT 2026-04-28, HR.01.06.03 was removed; its substance is split between HR.01.06.01 and HR.01.07.01.)
  16. 09The Joint Commission. Medical Staff. Standards MS.06.01.05 (objective evidence-based privilege evaluation), MS.08.01.01 (FPPE — required for all new privileges), and MS.08.01.03 (OPPE — codified ≤ 12-mo cycle). 2024. (Per CITATION_AUDIT 2026-04-28, the FPPE substance lives at MS.08.01.01, not MS.07.01.01.)
  17. 10California Code of Regulations. Title 16, §1474 (BRN standardized procedures); §1399.541 (PA performable medical services).
  18. 11CMS Conditions of Participation. 42 CFR §482.12(a)(6) (privileges based on individual competence) and §482.22(c)(6) (bylaws include privilege criteria).
  19. 12UCI APP Class 2 Training Plan Process. University of California, Irvine Health. April 2026.
  20. 13UCI FPPE Master Plan §5. University of California, Irvine Health. April 2026.
  21. 14Strauss SA, Ma GW, Seo C, et al. Ultrasound-guided versus anatomic landmark-guided percutaneous femoral artery access. Cochrane Database Syst Rev. 2025;3:CD014594. PMID 40152297.
Arterial Line Femoral · References
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UUCI · APP Class II
Procedure 04 · Arterial Line Femoral
End of module · Procedure 04

Now —
the post-test.

Stream A
15-item post-test
≥ 12/15
Stream B
24-item skills
checklist
Stream C
Sim center
HIGH-risk gate
Live
5 proctored cases
Independent ratings
Routing: IDPC → Credentials Committee → MEC → Board per UCI Medical Staff Bylaws.
Approving authority: Claire Henchcliffe, MD, DPhil · Chair, Department of Neurology.
UCI Health · APP Education
Version 2.0 · 2026-05-11
Arterial Line Femoral · End
21 / 21