The main indication to implant a long-term system by cannulation of the femoral vein is the presence of an obstruction of the superior vena cava, documented radiologically. These obstructions are often related to the same neoplastic disease that requires the placement of the port for chemotherapy. More rarely, the non-accessibility of the tributary veins of the superior cava can be secondary to bilateral thrombosis of the brachio-cephalic veins.
In these cases, the best approach is the ultrasound-guided puncture and cannulation of the common or superficial femoral vein. If the system is to be used only for infusions (and/or blood sampling), the tip can be placed in the central part of the inferior vena cava, above the bifurcation of the iliac veins and below the bifurcation of the renal veins.
If a totally implantable system is chosen, the most delicate problem lies in the location of the pocket for the reservoir. Both thoracic-abdominal pockets (with upward tunneling) and thigh pockets (with downward tunneling) are often unsatisfactory, because they are associated with risk of displacement of the reservoir or 'kinking' of the catheter, in case of a very long tunneling. For this reason, in many of these cases, the placement of a long-term system with an external catheter may be preferred: i.e., a cuffed-tunneled FICC or a tunneled FICC secured by subcutaneously anchored securement (SAS).