Central venous access sites to prevent venous blood clots, blood vessel narrowing, and infection

Central venous access (CVA) involves a large bore catheter inserted in a vein in the neck, upper chest or groin (femoral) area to give drugs that cannot be given by mouth or via a conventional needle (cannula or tube in the arm). CVA is widely used. However, its thrombotic (causing a blood clot) and infectious complications can be life-threatening and involve high-cost therapy. Research has revealed that the risk of catheter-related complications varies according to the sites of central venous catheter (CVC) insertion. It would be helpful to find the preferred site of insertion to minimize the risk of catheter-related complications. This review examined whether there was any evidence to show that CVA through any one site (neck, upper chest, or femoral area) is better than the other. Four studies were identified comparing data from 1513 participants. For the purpose of this review, three comparisons were evaluated: 1) internal jugular versus subclavian CVA routes; 2) femoral versus subclavian CVA routes; and 3) femoral versus internal jugular CVA routes. We compared short-term and long-term catheter insertion. We defined long-term as for more than one month and short-term as for less than one month, according to the Food and Drug Administration (FDA). No randomized controlled trial was found comparing all three CVA routes and reporting the complications of venous stenosis.

Subclavian and internal jugular CVA routes had similar risks for catheter-related complications in long-term catheter insertion in cancer patients. Subclavian CVA was preferable to femoral CVA in short-term catheter insertion because of lower risks of catheter colonization and thrombotic complications. In catheter insertion for short-term haemodialysis, femoral and internal jugular CVA routes had similar risks for catheter-related complications except internal jugular CVA routes were associated with higher risks of mechanical complications. Further trials comparing subclavian, femoral and jugular CVA routes are needed.

Authors' conclusions: 

Subclavian and internal jugular CVA routes have similar risks for catheter-related complications in long-term catheterization in cancer patients. Subclavian CVA is preferable to femoral CVA in short-term catheterization because of lower risks of catheter colonization and thrombotic complications. In short-term haemodialysis catheterization, femoral and internal jugular CVA routes have similar risks for catheter-related complications except internal jugular CVA routes are associated with higher risks of mechanical complications.

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Background: 

Central venous access (CVA) is widely used. However, its thrombotic, stenotic and infectious complications can be life-threatening and involve high-cost therapy. Research revealed that the risk of catheter-related complications varied according to the site of CVA. It would be helpful to find the preferred site of insertion to minimize the risk of catheter-related complications. This review was originally published in 2007 and was updated in 2011.

Objectives: 

1. Our primary objective was to establish whether the jugular, subclavian or femoral CVA routes resulted in a lower incidence of venous thrombosis, venous stenosis or infections related to CVA devices in adult patients.

2. Our secondary objective was to assess whether the jugular, subclavian or femoral CVA routes influenced the incidence of catheter-related mechanical complications in adult patients; and the reasons why patients left the studies early.

Search strategy: 

We searched CENTRAL (The Cochrane Library 2011, Issue 9), MEDLINE, CINAHL, EMBASE (from inception to September 2011), four Chinese databases (CBM, WANFANG DATA, CAJD, VIP Database) (from inception to November 2011), Google Scholar and bibliographies of published reviews. The original search was performed in December 2006. We also contacted researchers in the field. There were no language restrictions.

Selection criteria: 

We included randomized controlled trials comparing central venous catheter insertion routes.

Data collection and analysis: 

Three authors assessed potentially relevant studies independently. We resolved disagreements by discussion. Dichotomous data on catheter-related complications were analysed. We calculated relative risks (RR) and their 95% confidence intervals (CI) based on a random-effects model.

Main results: 

We identified 5854 citations from the initial search strategy; 28 references were then identified as potentially relevant. Of these, we Included four studies with data from 1513 participants. We undertook a priori subgroup analysis according to the duration of catheterization, short-term (< one month) and long-term (> one month) defined according to the Food and Drug Administration (FDA).

No randomized controlled trial (RCT) was found comparing all three CVA routes and reporting the complications of venous stenosis.

Regarding internal jugular versus subclavian CVA routes, the evidence was moderate and applicable for long-term catheterization in cancer patients. Subclavian and internal jugular CVA routes had similar risks for catheter-related complications. Regarding femoral versus subclavian CVA routes, the evidence was high and applicable for short-term catheterization in critically ill patients. Subclavian CVA routes were preferable to femoral CVA routes in short-term catheterization because femoral CVA routes were associated with higher risks of catheter colonization (14.18% or 19/134 versus 2.21% or 3/136) (n = 270, one RCT, RR 6.43, 95% CI 1.95 to 21.21) and thrombotic complications (21.55% or 25/116 versus 1.87% or 2/107) (n = 223, one RCT, RR 11.53, 95% CI 2.80 to 47.52) than with subclavian CVA routes. Regarding femoral versus internal jugular routes, the evidence was moderate and applicable for short-term haemodialysis catheterization in critically ill patients. No significant differences were found between femoral and internal jugular CVA routes in catheter colonization, catheter-related bloodstream infection (CRBSI) and thrombotic complications, but fewer mechanical complications occurred in femoral CVA routes (4.86% or 18/370 versus 9.56% or 35/366) (n = 736, one RCT, RR 0.51, 95% CI 0.29 to 0.88).

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