Imai E, Kataoka Y, Watanabe J, et al. Ultrasound-guided central venous catheterization around the neck: Systematic review and network meta-analysis. Am J Emerg Med. 2024 Apr;78:206-214. doi: 10.1016/j.ajem.2024.01.043. Epub 2024 Feb 3. (Systematic review)

BACKGROUND: Ultrasound-guided central venous catheterization (CVC) has become the standard of care. However, providers use a variety of approaches, encompassing the internal jugular vein (IJV), supraclavicular subclavian vein (SupraSCV), infraclavicular subclavian vein (InfraSCV), proximal axillary vein (ProxiAV), distal axillary vein (DistalAV), and femoral vein.

OBJECTIVE: This review aimed to compare the first-pass success rate and arterial puncture rate for different approaches to ultrasound-guided CVC above the diaphragm.

METHODS: In May 2023, Embase, MEDLINE, CENTRAL, ClinicalTrials.gov, and World Health Organization International Clinical Trials Platform were searched for randomized controlled trials (RCTs) comparing the 5 CVC approaches. The Confidence in Network Meta-Analysis tool was used to assess confidence. Thirteen RCTs (4418 participants and 13 comparisons) were included in this review.

RESULTS: The SupraSCV approach likely increased the proportion of first-attempt successes compared to the other 4 approaches. The SupraSCV first-attempt success demonstrated risk ratios (RRs) > 1.21 with a lower 95% confidence interval (CI) exceeding 1. Compared to the IJV, the SupraSCV approach likely increased the first-attempt success proportion (RR 1.22; 95% confidence interval [CI] 1.06-1.40, moderate confidence), whereas the DistalAV approach reduced it (RR 0.72; 95% CI 0.59-0.87, high confidence). Artery puncture had little to no difference across all approaches (low to high confidence).

CONCLUSION: Considering first-attempt success and mechanical complications, the SupraSCV may emerge as the preferred approach, while DistalAV might be the least preferable approach. Nevertheless, head-to-head studies comparing the approaches with the greatest first attempt success should be undertaken.

Discipline Area Score
Emergency Medicine 6 / 7
Intensivist/Critical Care 6 / 7
Comments from MORE raters

Emergency Medicine rater

This review and network meta-analysis with largely indirect comparisons is unlikely to change anyone's practice. It does (weakly) suggest that when using ultrasound, the supraclavicular approach leads to more first-attempt success compared with other methods, including the popular IJ approach. Physicians will, and probably should, continue to use the approach they are most comfortable with.

Intensivist/Critical Care rater

This is an extensive SR and network analysis. The only challenge is as with all U/S related work, it remains operator dependent. The Supraclav SVC approach is also not very popular outside the USA. We will mostly still use IC-SCV.
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