What’s the Best Target in the Neck for US Guided Central Access
May 22, 2024
Written by Chris Thom
Spoon Feed
This was a network meta-analysis of 13 randomized controlled trials comparing 5 different central venous catheterization (CVC) approaches. The supraclavicular subclavian (SupraSCV) demonstrated superior first-attempt success, while artery puncture was similar for all five locations.
Aim for the supraclavicular pocket
This network meta-analysis included 13 RCTs encompassing 4,418 participants. The trials were varied in their comparators, with five trials comparing SupraSCV to InfraSCV, three trials comparing proximal axillary vein (ProxiAV) to distal axillary vein (DistalAV), three trial comparing ProxiAV to internal jugular (IJ), one trial comparing InfraSCV to IJ, and one comparing SupraSCV to IJ. The meta-analysis methodology then sought to compare the common endpoints of first-attempt success, artery puncture, line failure, pneumothorax, hemothorax, and hematoma between the five anatomical sites.
Compared to the IJ site, SupraSCV increased first-attempt success (risk ratio, RR of 1.22; 95%CI 1.06-1.40). Conversely, DistalAV location reduced the first-attempt success (RR of 0.72, 95%CI 0.59-0.87). In indirect comparisons, the SupraSCV had a higher first-attempt success than all other approaches. The additional endpoints evaluated did not show any statistical differences other than a reduction in hematoma formation when using the SupraSCV approach, though the authors note this metric featured low confidence evidence.
How will this change my practice?
Ultrasound guided central lines are here to stay and the evidence continues to mount that they are superior to landmark for subclavian lines. Site selection within the subclavian region can include the SupraSCV, InfraSCV, DistalAV, and ProxiAV. This study adds to the evidence that the SupraSCV might be the best initial location to scout with your ultrasound probe and perhaps should be a focus of our educational efforts for ultrasound guided central lines.
Source
Ultrasound-guided central venous catheterization around the neck: Systematic review and network meta-analysis. Am J Emerg Med. 2024;78:206-214.