Central venous access is an important part of critical care and perioperative management in high-risk patients. The complication rate during vascular cannulation using traditional landmark approach amounts around 15%,1 and a recent Cochrane meta-analysis found a 71% reduction in complications using ultrasound.1 Although many studies have compared ultrasound and landmark techniques1–9 and have evaluated different ultrasound approaches,10–14 few studies have tested central venous access sites other than the internal jugular, femoral, or subclavian.
Internal jugular vein (IJV) cannulation is the most commonly studied site for central vein cannulation2–5 in adults, while the brachiocephalic vein (BCV) cannulation is an appropriate option for pediatric patients. The first description of successful ultrasound-guided BCV cannulation was by Breschan et al.15 Their approach describes placing the ultrasound probe in the supraclavicular region, and a longitudinal view of the junction of the IJV, the superior vena cava, and the BCV is obtained (Supplemental Digital Content 1, Video, http://links.lww.com/AA/C322). In many pediatric centers, the BCV has become a preferred option for central venous cannulation,15–17 but its use in adults remains limited and few studies compare the BCV to other cannulation sites.18
The aim of this study was to compare a BCV approach for central venous catheter (CVC) placement in adults with the established IJV approach for first pass success rate, procedural complication and failure rate, and complication rate (primary end point).
The ethics committee of our hospital approved our single-center cohort study and waived the need for informed consent due to its retrospective nature. The study cohort included all adult patients receiving, for the first time, an elective central venous cannulation in an upper body site between June 2012 and June 2014. None of these CVCs was positioned for surgery, all of these CVCs were requested by department team, mainly for patients with pathological medical condition (eg, infection, hematologic pathology) or due to impossibility to position peripheral vein line.
All procedures in this study were performed in a specialized room close to intensive care unit, used only for elective CVC placement for hospitalized patients. We excluded patients undergoing emergent or urgent procedures, or ventilated patients because procedures for these patients were usually performed outside the dedicated room.
Patients were then classified as having undergone cannulation via the IJV or the BCV approaches.
The site (IJV or BCV) for catheter placement was based on the existing algorithm (Figure 1) developed in our department.
For the purposes of the present study, we recorded procedural difficulties, success at the first attempt, and overall failure. Major or minor complications (defined below) were recorded and collected.
Clinical data were retrieved from the departmental database for CVC implantation. The following data were recorded:
- Preprocedural variables: demographics (age, height, weight); coagulation parameters: international normalized ratio of the prothrombin time (international normalized ratio), ratio of the activated partial thromboplastin time, and platelet count.
- Procedural data: Technical variables: vein of choice (IJV or BCV); side of insertion (right or left); out-of plane or in-plane technique.
- Outcome data
- • Success at the first attempt; procedural difficulties; insertion failure.
- • safety:
- • complications immediately identified during procedure, including arterial puncture-hematoma, vein transfixion, and thyroid puncture;
- • complications identified after chest radiography: hemothorax and pneumothorax
We did not collect any data after the chest X-ray was performed.
Definitions of the Outcomes
- Major complications: pneumothorax, hemothorax (both diagnosed by chest radiography); arterial puncture diagnosed via immediate ultrasound visualization (direct evidence of artery puncture due to a wrong needle movement).
- Minor complications: hematoma, vein transfixion, and thyroid puncture, diagnosed via immediate ultrasound visualization.
Coagulopathy: any of the following international normalized ratio >1.5, activated partial thromboplastin time ratio >1.5, or platelet count ≤50 × 109/L).19
Procedural difficulty: unable to pass guidewire and/or more than 2 punctures in the same site.
Failure: Inability to insert the catheter into the first chosen site (at least 3 attempts) and/or the need to site or side change.
All ultrasound-guided techniques were performed using the LOGIQe ultrasound device (General Electric, Fairfield, CT). A 6–12 MHz linear-array ultrasound probe was used in all cases. All procedures were performed with a modified guidewire technique using an 18-G introducer needle connected to a 5-mL Raulerson spring-wire syringe (Arrow catheterization set).
All procedures were performed in a dedicated room into the general ICU of our institute.
All procedures were performed by 1 of 4 operators, each certified by a completed specific ultrasound vascular access course. Each operator independently performed at least 30 correct procedures for each approach before participating in the study.
The CVC placement was performed following these steps:
- Vessel selection (IJV and BCV) following our algorithm (Figure 1);
- Rapid Central Vein Assessment20 to confirm the selected site. In this protocol, the ultrasound probe was placed transversally on the neck under the mandibular angle to capture an image of anatomical structures, then the probe was slid in a caudal direction until carotid artery and the IJV short axis visualization was obtained. The 2 vascular structures were then followed caudally until the probe reached the neck, compressing the vessels to distinguish the artery from the vein and to evaluate vein patency. The BCV longitudinal view was obtained with the probe first positioned on the neck to visualize the IJV, then sliding caudally till contacting the clavicle (Figure 2), then directing the ultrasound beam into the chest until the confluence of IJV, subclavian vein, and BCV was represented. The same inspection was performed on the contralateral side (Supplemental Digital Content 1, Video, http://links.lww.com/AA/C322).
- The procedure was conducted with maximal sterile barrier precautions21: the selected site was prepared using ChloraPrep (Carefusion UK, San Diego, CA) and the ultrasound probe was covered with ultrasonic gel and wrapped in a sterile plastic sheath.
- After guidewire insertion, its course into the vein was checked by ultrasound before catheter insertion.
Our primary aim was to compare the success at the first attempt, procedural difficulties, insertion failure, and number of complications with insertions via the IJV versus the BCV.
The characteristics of the study population were described using frequency distributions for categorical variables and mean and standard deviation values, median, and interquartile range for continuous variables, depending on the normality of distribution. Pearson’s χ2test or Fisher exact test (as appropriate) was applied to compare categorical factors across study arms. Odds ratio with 95% confidence intervals were produced accordingly. Baseline potentially confounding variables which were different between the study arms at a P value <.1 were entered into a multivariable logistic regression analysis, to assess their independent association with the outcomes. Within multivariable models, odds ratios and 95% confidence intervals were produced.
A preliminary power analysis was performed, based on a complication rate of 10% in the IJV arm and 5% in the BCV arm. With an α value of .05 and a power of 80%, a total of 868 patients was needed. Our patient population was considered adequate. All tests were 2 sided, and a P value <.05 was considered statistically significant. Statistical analyses were performed using STATA 13 software (STATACorp, College Station, TX).
During the study period, 994 patients underwent elective CVC placement in the upper body. Of these, 709 patients received the catheter in IJV and 285 in BCV. These patients constituted the study population.
Preinsertion data between groups are summarized in Table 1. Seventy hundred twenty-three patients underwent right-sided CVC insertion (510 IJV and 213 BCV) and 271 underwent left-sided insertion (199 IJV and 72 BCV).
Overall success and complications rates are summarized in Table 2. Thirty-four procedures (3.4%) were unsuccessful and required a change of insertion site. The reasons for that change are listed in Supplemental Digital Content 2, Figure 1, http://links.lww.com/AA/C323.
Pneumothorax and hemothorax were the only 2 complications not immediately identified with ultrasound. Overall 9 patients (0.9%) had pneumothorax, all of these patients received a catheter in the correct position at the first attempt. Overall 18 patients (1.8%) had hemothorax. Of these, 16 occurred on the first attempt, 1 on the second attempt, and 1 after a difficult procedure and failed placement in the first chosen site (right BCV). In the last case, the CVC was ultimately positioned in the left IJV with the short axis in-plane approach.
Primary Outcome Results
A multivariable model was created to identify factors associated with procedural difficulties and first attempt success rates (Table 3). After adjusting for potential confounding variables, BVC was associated with an estimated 62% lower odds of procedural difficult compared to IJV, with odds ratio (95% CI) of 0.38 (0.10–0.76); P = .007 (Table 3). The only additional independent factor was the presence of a coagulopathy of any kind, with odds ratio (95% CI) of 0.32 (0.11–0.89), P = .029.
In this retrospective comparison of ultrasound-guided central line insertions via the BCV and IJV sites, we found that CVC insertion at the BCV site was associated with a lower rate of procedural difficulty than insertion at the IJV site.
Approximately 6 million central venous catheterizations are performed each year in Europe and United States.1 Most of these target the IJ, subclavian, or femoral veins.
Central venous access via the BCV vein is well described by Breschan et al15 in children, is a frequent choice in pediatric patients, and has been described as safe and effective.18 However, few studies considered BCV in adults.18
To obtain the longitudinal view of BCV, the ultrasound probe is placed in the supraclavicular region parallel to the clavicle, and the IJV is tracked distally until the junction with subclavian vein is obtained. An in-plane longitudinal approach with the needle is then used (Figure 1).
The resulting ultrasound view is shown in Figure 2. The needle in the in-plane approach to BCV is safely positioned with respect to the pleura, easy visualized together with BCV, and of the subclavian artery (Figure 3). The guidewire then advances along the longitudinal axis of the vein, follows the vessel route closely.
The mechanism underlying the lower incidence of difficult cannulation we observed with the BCV approach is unclear. However, the BCV has several anatomical advantages over the IJV: due to thin tissue trabeculae, the BCV lumen is stented open regardless of hemodynamic and respiratory status, overlap with the carotid or brachiocephalic artery is rare, and the catheter insertion site exit is located away from the naso-buccal area, reducing oropharyngeal flora contamination.13,16,22 In addition, the BCV is easily identified by ultrasound.
We also found that coagulopathy was an independent factor predicting a greater success rate and lower procedural difficulty rate. This paradoxical observation may be due to increased attention when a known risk factor for major bleeding was present.
Our findings have led to changes in our daily clinical practice. As a result of the decreased incidence of difficult cannulations with BCV, we now prefer the BCV to IJV for central venous access.
In light of its anatomical characteristics, we avoid the BCV in 2 conditions (Figure 1): when a dialysis catheter is required because this device requires a straight course into the vessel, the BCV approach does not allow this. As a relative contraindication, the presence of a coagulopathy could be considered, due to a difficult compression of the BCV if bleeding is encountered.
We conclude that the ultrasound-guided BCV approach to central vein cannulation is an alternate site for central vein cannulation that had fewer complications in our hands. Clinicians should consider the BCV for nondialysis CVC placement (Supplemental Digital Content 3, Figure 2, http://links.lww.com/AA/C324).
The main limitation of our study is retrospective, nonrandomized nature. As a result, patients undergoing SCV cannulation may have differed from those undergoing IJV cannulation. In addition, as a consequence of the retrospective collection, data may be missing which may possibly be useful in the identification of the best CVC cannulation site. A second major limitation is the lack of follow-up data on long-term complication rate (infection, vein stenosis, or thrombosis).
Name: Paolo Federico Beccaria, MD.
Contribution: This author helped with conception and design of the study, interpretation of data for the study, drafting the study, revising it critically for important intellectual content, and final approval of the article.
Name: Simona Silvetti, MD.
Contribution: This author helped with acquisition of data design the study, analysis of data for the study, interpretation of data for the study, and drafting the study.
Name: Rosalba Lembo, MSC.
Contribution: This author helped analyze the data for the study.
Name: Giovanni Landoni, MD.
Contribution: This author helped with the interpretation of data for the study and revising it critically for important intellectual content.
Name: Giacomo Monti, MD.
Contribution: This author helped with the acquisition of data for the study.
Name: Massimo Zambon, MD.
Contribution: This author helped with the acquisition of data for the study.
Name: Daniela Mamo, MD.
Contribution: This author helped with the acquisition of data for the study.
Name: Alberto Zangrillo, MD.
Contribution: This author helped with the final approval of the article.
This manuscript was handled by: Avery Tung, MD, FCCM.
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