Choice of Venous Sites. Percutaneous Implant/Technique/US Guidance

Abstract

The percutaneous approach to the subclavian or internal jugular vein is currently the most popular procedure for placing central venous catheters in the superior vena cava, both for short- and long-term use. There is compelling evidence that ultrasound (US)-guided venipuncture (with realtime ultrasonography) is associated with a substantial benefit, and US support is therefore strongly recommended (Grade A) for all central venous catheter insertions. Concerns have been raised with respect to training, as the novel techniques should be incorporated into the US courses that are currently being set up for radiologists, anesthesiologists, and surgeons. Moreover, the landmark method would remain important for emergencies when US equipment and/or expertise might not be immediately available. A recent randomized trial concluded that central venous insertion modality and sites had no impact on either early or late complication rates when performed by experienced operators, but US-guided insertion showed the lowest proportion of failures. While many RCTs have clearly shown that US guidance is superior to the landmark technique - at least in terms of immediate outcome - for internal jugular vein cannulation in a variety of clinical settings, doubts still persist for the subclavian insertion site. A very recent RCT in ICU patients has suggested that US-guided cannulation of the subclavian vein is superior to the landmark method in terms of average access time, number of attempts, frequency of artery puncture, hematoma, hemothorax, pneumothorax, brachial plexus and phrenic nerve injury. More studies are needed to address long-term benefits (if any) and cost-effectiveness.