Clinical Application of Shenton’s Line to Determine the Femoral Artery Bifurcation Using the Antegrade Common Femoral Artery Approach
The common femoral artery (CFA) is one of the most frequently used access routes for surgical interventions, particularly in the treatment of lower extremity artery disease. However, identifying the distal end of the CFA, where it bifurcates into the deep femoral artery (DFA) and the superficial femoral artery (SFA), can be challenging, especially during antegrade femoral artery puncture. This difficulty has led to the exploration of various anatomical landmarks to improve the accuracy of locating the femoral artery bifurcation. Among these landmarks, Shenton’s line has emerged as a promising tool due to its clarity and ease of identification on X-ray imaging.
Shenton’s line is an anatomical marker commonly used in orthopedics to assess hip dislocation or fractures. It is defined as the arc line connecting the internal lateral margin of the femur neck and the inferior margin of the pubic bone in a normal anteroposterior radiograph of the pelvis. Given its distinct visibility on X-ray, Shenton’s line was investigated in this study as a potential landmark for determining the femoral artery bifurcation.
The study was conducted as a retrospective analysis involving 365 patients with lower extremity arteriosclerosis occlusive disease who underwent computed tomography angiography (CTA) at Beijing Luhe Hospital, Capital Medical University, between February 2017 and November 2020. After excluding cases with femoral head necrosis, femoral neck or intertrochanteric fractures, and anatomical variations of the femur or femoral artery, 338 cases were included in the final analysis. The patients’ baseline data, including sex, age, weight, height, and body mass index (BMI), were collected. The relationship between the CFA bifurcation and three anatomical lines—the midpoint of the femoral head, Shenton’s line, and the lower margin of the femoral head—was analyzed using CTA.
The femoral head was divided into four zones based on these three lines. The position of the femoral artery bifurcation was determined, and its distance from each line was measured. A negative value indicated that the bifurcation point was above the line, while a positive value indicated it was below the line. The distribution of bifurcation points across the four zones was statistically analyzed, and comparisons were made between the left and right sides. To account for the potential influence of BMI on the bifurcation point, patients were stratified into four groups according to Chinese BMI category standards: underweight, normal weight, overweight, and obese.
The results showed that the majority of femoral artery bifurcation points were located below the midpoint of the femoral head, with 96.7% on the left side and 98.5% on the right side. Similarly, 84.6% of bifurcation points on the left side and 85.5% on the right side were below Shenton’s line. Overall, 85.1% of bifurcation points were below or on Shenton’s line, and 30.3% were directly on Shenton’s line. These findings suggest that Shenton’s line is a reliable anatomical marker for locating the femoral artery bifurcation.
The study also compared the bifurcation points of the left and right femoral arteries. The Bowker test revealed no significant difference in the distribution of bifurcation points between the two sides. In 79.9% of cases, the bifurcation positions were consistent on both sides, indicating that if the bifurcation point on one side was high or very high, the same was likely true for the other side. Conversely, if the bifurcation point on one side was normal, the other side was also likely to be normal.
To further explore the impact of BMI on the femoral artery bifurcation, the Kruskal-Wallis H test was performed, stratified by sex. The results showed no significant difference in bifurcation location across BMI categories, suggesting that BMI does not influence the position of the femoral artery bifurcation.
The study’s findings have practical implications for clinical practice. The use of Shenton’s line as a landmark for antegrade femoral artery puncture was applied in 52 patients at Beijing Luhe Hospital between January 2019 and November 2020. The technical success rate of the procedure reached over 90%, demonstrating the effectiveness of this approach. By improving the accuracy of puncture, the procedure time can be shortened, and operational efficiency can be enhanced. Additionally, confirming the femoral artery bifurcation point and the femoral head using CTA before surgery can further increase safety and precision.
The study also highlighted the importance of bilateral comparison in determining the femoral artery bifurcation. Among the Chinese population included in the study, a higher bifurcation point on one side was often associated with a higher bifurcation point on the other side. This observation provides valuable guidance for improving the success rate of bilateral puncture procedures. However, the authors emphasized that prior imaging data, such as CTA or angiography, should still be carefully reviewed to confirm the location of the bifurcation point.
Despite its contributions, the study has some limitations. First, the sample size was relatively small, and further research with larger cohorts is needed to validate the findings. Second, the study focused exclusively on Chinese patients, and the results may not be generalizable to other ethnic groups. Future studies should investigate the applicability of Shenton’s line as a landmark in diverse populations.
In conclusion, Shenton’s line is a clear and easily identifiable anatomical marker on X-ray that can be used to determine the femoral artery bifurcation. In 85.1% of Chinese patients included in this study, the bifurcation point was located below or on Shenton’s line, and in nearly one-third of cases, it was directly on Shenton’s line. There was no significant difference in the bifurcation points of the left and right femoral arteries, and BMI did not influence the bifurcation location. Puncture above Shenton’s line is reliable in most cases, and this approach can improve the success rate of antegrade femoral artery puncture procedures. The findings of this study provide valuable insights for vascular surgeons and contribute to the ongoing efforts to enhance the accuracy and safety of femoral artery access.
doi.org/10.1097/CM9.0000000000001873
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