Site-specific complications of central venous catheterization under systematic ultrasound guidance: a target trial emulation revisiting the 3SITES study.

Summary

In a target trial emulation assuming universal ultrasound guidance, subclavian CVCs had fewer catheter-related bloodstream infections and symptomatic DVTs versus jugular and femoral, with no significant increase in major mechanical complications. These results support preferring subclavian access in modern ultrasound-guided practice.

Key Findings

• Primary composite (CRBSI or symptomatic DVT) lower with subclavian vs femoral (P=.02) and vs jugular (P=.001)
• CRBSI significantly fewer with subclavian vs jugular (P=.001); asymptomatic thrombosis more frequent at femoral and jugular sites
• Major mechanical complications were rare and did not differ significantly across sites; n=3409 catheters

Clinical Implications

When feasible, prefer subclavian site under real-time ultrasound with strict sterile technique and trained operators to reduce CRBSI and DVT risks without increasing major mechanical complications.

Limitations

• Observational emulation subject to residual confounding and modeling assumptions
• Original dataset had limited ultrasound use; counterfactual extrapolation may not capture all nuances

Future Directions

Prospective comparative studies under mandatory ultrasound guidance; operator training standards and bundle approaches to further reduce CVC complications.