Intensive Care Medicine

, Volume 45, Issue 7, pp 968–976 | Cite as

Complications in internal jugular vs subclavian ultrasound-guided central venous catheterization: a comparative randomized trial

  • Hyun-Jung Shin
  • Hyo-Seok Na
  • Won-Uk Koh
  • Young-Jin Ro
  • Jung-Man Lee
  • Yoon-Ji Choi
  • Seongjoo Park
  • Jin-Hee KimEmail author



The use of real-time ultrasound (US) has been shown to reduce complications of central venous (CV) catheterization. However, complication rates have not been compared according to insertion points for CV catheterization using US. Accordingly, this study aimed to compare the complication rates of internal jugular vein (IJV) with those of subclavian vein (SCV) catheterization.


Three tertiary academic hospitals in South Korea participated in this multicenter, randomized study. A total of 1484 patients were preoperatively randomized into two groups. The IJV group (n = 742) was cannulated via the right IJV, and the SCV group (n = 742) was cannulated via the right SCV under US guidance. The primary outcome measure was total complication rate. Secondary outcomes included access time for the first attempt, number of attempts, and catheter position.


The total complication rate did not demonstrate a significant difference between the IJV (0.1%) and SCV (0.7%) groups (P = 0.248). In the IJV group, arterial puncture occurred in 0.1% of patients; in the SCV group, arterial puncture occurred in 0.6% and pneumothorax in 0.1%. The success rate on the first attempt was significantly higher in the IJV group (98.4%) than in the SCV group (95.9%) (P = 0.004). The access time for the first attempt (P < 0.001) and the median number of attempts (P = 0.006) were significantly lower in the IJV group than in the SCV group. More catheter misplacements were observed in the SCV group (5.9%) than in the IJV group (0.4%) (P < 0.001).


Results demonstrated that the complication rates of IJV and SCV catheterizations using US are very low, showing no superiority of the SCV approach compared to the IJV.


Central venous catheterization Jugular vein Subclavian vein Ultrasound Complication 


Author contributions

HJS: performing the procedure, writing the first manuscript, and statistical analysis; HSN: study design, writing the first manuscript, and statistical analysis; WUK: performing the procedure; YJR: study design and revising the manuscript; YJC: performing the procedure; JML: performing the procedure; S Park: performing the procedure; JHK: performing the procedure, revision and final approval of the version to be submitted.


There is no funding source.

Compliance with ethical standards

Conflicts of interest

All authors report no conflict of interest.

Ethical approval

This study was conducted in accordance with the Declaration of Helsinki and was approved by the local research ethics committee.


  1. 1.
    McGee DC, Gould MK (2003) Preventing complications of central venous catheterization. N Engl J Med 348:1123–1133CrossRefGoogle Scholar
  2. 2.
    Hoffman T, Du Plessis M, Prekupec MP, Gielecki J, Zurada A, Tubbs RS, Loukas M (2017) Ultrasound-guided central venous catheterization: a review of the relevant anatomy, technique, complications, and anatomical variations. Clin Anat 30:237–250CrossRefGoogle Scholar
  3. 3.
    Gordon AC, Saliken JC, Johns D, Owen R, Gray RR (1998) US-guided puncture of the internal jugular vein: complications and anatomic considerations. J Vasc Interv Radiol 9:333–338CrossRefGoogle Scholar
  4. 4.
    Turba UC, Uflacker R, Hannegan C, Selby JB (2005) Anatomic relationship of the internal jugular vein and the common carotid artery applied to percutaneous transjugular procedures. Cardiovasc Intervent Radiol 28:303–306CrossRefGoogle Scholar
  5. 5.
    Beaudoin FL, Merchant RC, Lincoln J, Gardiner F, Liebmann O, Cohn J (2011) Bedside ultrasonography detects significant femoral vessel overlap: implications for central venous cannulation. CJEM 13:245–250CrossRefGoogle Scholar
  6. 6.
    Troianos CA, Hartman GS, Glas KE, Skubas NJ, Eberhardt RT, Walker JD, Reeves ST (2012) Special articles: guidelines for performing ultrasound guided vascular cannulation: recommendations of the American Society of Echocardiography and the Society Of Cardiovascular Anesthesiologists. Anesth Analg 114:46–72CrossRefGoogle Scholar
  7. 7.
    Saugel B, Scheeren TWL, Teboul JL (2017) Ultrasound-guided central venous catheter placement: a structured review and recommendations for clinical practice. Crit Care 21:225CrossRefGoogle Scholar
  8. 8.
    American College of Emergency Physicians (2006) Emergency ultrasound imaging criteria compendium. Ann Emerg Med 48:487–510CrossRefGoogle Scholar
  9. 9.
    Rupp SM, Apfelbaum JL, Blitt C, Caplan RA, Connis RT, Domino KB, Fleisher LA, Grant S, Mark JB, Morray JP, Nickinovich DG, Tung A (2012) Practice guidelines for central venous access: a report by the American Society of Anesthesiologists Task Force on Central Venous Access. Anesthesiology 116:539–573CrossRefGoogle Scholar
  10. 10.
    National Institute for Health and Clinical Excellence (2002) NICE Technology Appraisal No 49: guidance on the use of ultrasound locating devices for placing central venous catheters. Accessed 25 Apr 2018
  11. 11.
    Smith RN, Nolan JP (2013) Central venous catheters. BMJ 347:f6570CrossRefGoogle Scholar
  12. 12.
    Cavanna L, Civardi G, Vallisa D, Di Nunzio C, Cappucciati L, Berte R, Cordani MR, Lazzaro A, Cremona G, Biasini C, Muroni M, Mordenti P, Gorgni S, Zaffignani E, Ambroggi M, Bidin L, Palladino MA, Rodino C, Tibaldi L (2010) Ultrasound-guided central venous catheterization in cancer patients improves the success rate of cannulation and reduces mechanical complications: a prospective observational study of 1978 consecutive catheterizations. World J Surg Oncol 8:91CrossRefGoogle Scholar
  13. 13.
    Fragou M, Gravvanis A, Dimitriou V, Papalois A, Kouraklis G, Karabinis A, Saranteas T, Poularas J, Papanikolaou J, Davlouros P, Labropoulos N, Karakitsos D (2011) Real-time ultrasound-guided subclavian vein cannulation versus the landmark method in critical care patients: a prospective randomized study. Crit Care Med 39:1607–1612CrossRefGoogle Scholar
  14. 14.
    Denys BG, Uretsky BF, Reddy PS (1993) Ultrasound-assisted cannulation of the internal jugular vein. A prospective comparison to the external landmark-guided technique. Circulation 87:1557–1562CrossRefGoogle Scholar
  15. 15.
    Sulek CA, Blas ML, Lobato EB (2000) A randomized study of left versus right internal jugular vein cannulation in adults. J Clin Anesth 12:142–145CrossRefGoogle Scholar
  16. 16.
    Teichgraber UK, Benter T, Gebel M, Manns MP (1997) A sonographically guided technique for central venous access. AJR Am J Roentgenol 169:731–733CrossRefGoogle Scholar
  17. 17.
    Randolph AG, Cook DJ, Gonzales CA, Pribble CG (1996) Ultrasound guidance for placement of central venous catheters: a meta-analysis of the literature. Crit Care Med 24:2053–2058CrossRefGoogle Scholar
  18. 18.
    Hind D, Calvert N, McWilliams R, Davidson A, Paisley S, Beverley C, Thomas S (2003) Ultrasonic locating devices for central venous cannulation: meta-analysis. BMJ 327:361CrossRefGoogle Scholar
  19. 19.
    Schmidt GA, Blaivas M, Conrad SA, Corradi F, Koenig S, Lamperti M, Saugel B, Schummer W, Slama M (2019) Ultrasound-guided vascular access in critical illness. Intensive Care Med 45:434–446CrossRefGoogle Scholar
  20. 20.
    Brass P, Hellmich M, Kolodziej L, Schick G, Smith AF (2015) Ultrasound guidance versus anatomical landmarks for internal jugular vein catheterization. Cochrane Database Syst Rev 1: CD006962Google Scholar
  21. 21.
    Brass P, Hellmich M, Kolodziej L, Schick G, Smith AF (2015) Ultrasound guidance versus anatomical landmarks for subclavian or femoral vein catheterization. Cochrane Database Syst Rev 1: CD011447Google Scholar
  22. 22.
    Rezayat T, Stowell JR, Kendall JL, Turner E, Fox JC, Barjaktarevic I (2016) Ultrasound-guided cannulation: time to bring subclavian central lines back. West J Emerg Med 17:216–221CrossRefGoogle Scholar
  23. 23.
    Shah A, Smith A, Panchatsharam S (2013) Ultrasound-guided subclavian venous catheterisation - is this the way forward? A narrative review. Int J Clin Pract 67:726–732CrossRefGoogle Scholar
  24. 24.
    Gibson F, Bodenham A (2013) Misplaced central venous catheters: applied anatomy and practical management. Br J Anaesth 110:333–346CrossRefGoogle Scholar
  25. 25.
    Bowdle A (2014) Vascular complications of central venous catheter placement: evidence-based methods for prevention and treatment. J Cardiothorac Vasc Anesth 28:358–368CrossRefGoogle Scholar
  26. 26.
    Griswold-Theodorson S, Farabaugh E, Handly N, McGrath T, Wagner D (2013) Subclavian central venous catheters and ultrasound guidance: policy vs practice. J Vasc Access 14:104–110CrossRefGoogle Scholar
  27. 27.
    Marik PE, Flemmer M, Harrison W (2012) The risk of catheter-related bloodstream infection with femoral venous catheters as compared to subclavian and internal jugular venous catheters: a systematic review of the literature and meta-analysis. Crit Care Med 40:2479–2485CrossRefGoogle Scholar
  28. 28.
    Ruesch S, Walder B, Tramer MR (2002) Complications of central venous catheters: internal jugular versus subclavian access—a systematic review. Crit Care Med 30:454–460CrossRefGoogle Scholar
  29. 29.
    Tokumine J, Matsushima H, Lefor AK, Igarashi H, Ono K (2015) Ultrasound-guided subclavian venipuncture is more rapidly learned than the anatomic landmark technique in simulation training. J Vasc Access 16:144–147CrossRefGoogle Scholar
  30. 30.
    Gualtieri E, Deppe SA, Sipperly ME, Thompson DR (1995) Subclavian venous catheterization: greater success rate for less experienced operators using ultrasound guidance. Crit Care Med 23:692–697CrossRefGoogle Scholar
  31. 31.
    Vezzani A, Manca T, Brusasco C, Santori G, Cantadori L, Ramelli A, Gonzi G, Nicolini F, Gherli T, Corradi F (2017) A randomized clinical trial of ultrasound-guided infra-clavicular cannulation of the subclavian vein in cardiac surgical patients: short-axis versus long-axis approach. Intensive Care Med 43:1594–1601CrossRefGoogle Scholar
  32. 32.
    Frankel HL, Kirkpatrick AW, Elbarbary M, Blaivas M, Desai H, Evans D, Summerfield DT, Slonim A, Breitkreutz R, Price S, Marik PE, Talmor D, Levitov A (2015) Guidelines for the appropriate use of bedside general and cardiac ultrasonography in the evaluation of critically ill patients-part I: general ultrasonography. Crit Care Med 43:2479–2502CrossRefGoogle Scholar
  33. 33.
    Lamperti M, Bodenham AR, Pittiruti M, Blaivas M, Augoustides JG, Elbarbary M, Pirotte T, Karakitsos D, Ledonne J, Doniger S, Scoppettuolo G, Feller-Kopman D, Schummer W, Biffi R, Desruennes E, Melniker LA, Verghese ST (2012) International evidence-based recommendations on ultrasound-guided vascular access. Intensive Care Med 38:1105–1117CrossRefGoogle Scholar
  34. 34.
    Chittoodan S, Breen D, O'Donnell BD, Iohom G (2011) Long versus short axis ultrasound guided approach for internal jugular vein cannulation: a prospective randomised controlled trial. Med Ultrason 13:21–25Google Scholar
  35. 35.
    Shrestha GS, Gurung A, Koirala S (2016) Comparison between long- and short-axis techniques for ultrasound-guided cannulation of internal jugular vein. Ann Card Anaesth 19:288–292CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Anesthesiology and Pain MedicineSeoul National University Bundang HospitalBundang-gu, Seongnam-siSouth Korea
  2. 2.Department of Anesthesiology and Pain MedicineAsan Medical CenterSeoulSouth Korea
  3. 3.Department of Anesthesiology and Pain MedicineSeoul Metropolitan Government Seoul National University Boramae Medical CenterSeoulSouth Korea
  4. 4.Department of Anesthesiology and Pain MedicineKorea University Ansan HospitalAnsan-siSouth Korea
  5. 5.Department of Anesthesiology and Pain MedicineSeoul National University College of MedicineSeoulSouth Korea

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