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Reassessing the Risk: A Retrospective Analysis of CLABSI Risk in Femoral, Internal Jugular, and Subclavian Central
Alexandra Vaughan-Masamitsu1, Wesley Paulson1, Robert Hodes2
1Penn State College of Medicine, Pennsylvania State University, Hershey, Pennsylvania, USA.
Insights
Central line-associated bloodstream infections (CLABSIs) are a concern, but this study found no increased risk for femoral vein (FV) central venous catheter (CVC) placement compared to internal jugular vein (IJV) or subclavian vein (SCV) sites. These findings suggest FV CVCs are a safe option, potentially expanding clinical choices.
Area of Science:
- Infectious Diseases
- Vascular Access
- Patient Safety
Background:
- Central line-associated bloodstream infections (CLABSIs) pose significant risks, including increased morbidity, mortality, and costs.
- Current guidelines often recommend against femoral vein (FV) central venous catheter (CVC) placement due to perceived higher infection risks compared to internal jugular (IJV) or subclavian (SCV) sites.
- Emerging evidence suggests that infection risks may be comparable across different CVC insertion sites, necessitating a re-evaluation of current practices.
Purpose of the Study:
- To challenge the prevailing notion that femoral CVCs are associated with a higher risk of CLABSI compared to IJV and SCV sites.
- To provide a data-driven comparison of CLABSI risk across FV, IJV, and SCV central line insertion sites.
- To inform clinical decision-making regarding CVC placement by reassessing site-specific infection risks.
Main Methods:
- A retrospective cohort analysis was conducted using the TriNetX Research Network, including 99,216 patients undergoing CVC placement between 2014 and 2025.
- Propensity score matching was applied, retaining 65,265 patients categorized by CVC insertion site: IJV, SCV, or FV.
- CLABSI incidence was identified using ICD-10-CM codes within one month post-insertion, with sensitivity analyses performed for different time periods (2014-2025, 2014-2019, 2019-2025).
Main Results:
- The study found no statistically significant difference in CLABSI risk between femoral CVCs and IJV or SCV CVCs across the entire 2014-2025 period.
- A statistically significant higher risk of CLABSI was observed for IJV CVCs compared to SCV CVCs (risk difference: 0.089%, 95% CI: 0.006% to 0.171%).
- No significant differences in CLABSI risk were detected between IJV and FV cohorts in sensitivity analyses for the 2014-2019 and 2019-2025 periods.
Conclusions:
- The findings challenge the assumption that femoral vein CVCs inherently carry a higher CLABSI risk than internal jugular or subclavian sites.
- Avoiding the femoral vein solely due to infection concerns may unnecessarily restrict clinical options without improving patient outcomes.
- Clinical decisions for CVC placement should consider site-specific technical and anatomical factors alongside infection risks to optimize patient care.
Abstract:
Background: Central line-associated bloodstream infections (CLABSIs) represent a significant healthcare challenge due to their association with increased morbidity, mortality, and financial burden. Current guidelines discourage the use of the femoral vein (FV) for central venous catheter (CVC) placement due to a perceived higher infection risk compared to the internal jugular vein (IJV) or subclavian (SCV) sites. However, recent evidence questions this assumption and suggests that femoral CVCs may carry similar risks to other sites, emphasizing the need for updated analyses. Objective: The goal of this study was to address the misconception that femoral CVCs have a higher associated risk for developing CLABSI compared to other central line sites. This study evaluates risk for CLABSI across FV, IJV, and SCV sites. Methods: Using the TriNetX Research Network to conduct a retrospective cohort analysis, initial queries identified 99,216 patients who were encountered between 2014 and 2025 for CVC placement. Following propensity score matching, 65,265 of these patients were retained for statistical analysis. Patients were categorized based on anatomic CVC placement sites into IJV, SCV, and FV cohorts. CLABSI incidence was determined using ICD-10-CM codes within 1 day to 1 month post-CVC insertion. Sensitivity analyses were conducted for the 2014-2025 period, as well as for the 2014-2019 and 2019-2025 periods to assess overall risk and evaluate for changes in CLABSI risk by anatomic site over time. Outcomes were compared using risk percentages, risk ratios, and odds ratios with 95% confidence intervals to compare differences in risk for CLABSI across different sites. Results: Overall, femoral CVCs were not associated with a statistically significant higher risk of CLABSI compared to IJV or FV CVCs from the overall period of 2014-2025. Only the risk difference between IJV and SCV CVCs over 2014-2025 showed a statistically significant difference. IJV CVCs were associated with a higher risk of CLABSI compared with SCV CVCs, with a risk difference of 0.089% (95% CI: 0.006%, 0.171%, Z = 2.11, p=0.0348), a risk ratio of 1.708 (95% CI: 1.033, 2.826), and an odds ratio of 1.71 (95% CI:1.033, 2.831). Over the 2014-2019 period, there was no statistically significant risk difference between the IJV and FV cohorts (risk difference 0.09%, 95% CI: -0.035%, 0.215%, Z = 1.415, p=0.1569). Comparing the IJV to SCV CLABSI rates for the 2014-2019 period, the risk difference was 0.112% (95% CI: -0.009%, 0.234%, Z = 1.81, p=0.07). For the 2019-2025 period between the IJV and FV cohorts, the risk difference was -0.077% (higher risk in the FV cohort), which was not a statistically significant difference (95% CI: -0.193%, 0.04%, Z = -1.289, p=0.1974). Comparing the IJV to SCV CLABSI rates for the 2019-2025 period, the risk difference was 0.117% (95% CI: = -0.006%, 0.24%, Z = 1.861, p=0.0627), which was not a statistically significant difference. Conclusions: This study challenges the prevailing assumption that femoral CVCs carry a higher risk of CLABSI compared to IJV and SCV sites, showing no significant difference in risk. These findings suggest that avoidance of the FV for CVC placement out of concern for infection may unnecessarily limit clinical options without improving patient outcomes. Emphasizing site-specific risks like technical complications and anatomical considerations over infection concerns could simplify decision-making and enhance personalized care in CVC placement.
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