Real-time Ultrasound-guided Subclavian Vein Cannulation versus the Landmark Method in Critical Care Patients

A Prospective Randomized Study

Mariantina Fragou, MD; Andreas Gravvanis, MD, PhD; Vasilios Dimitriou, MD, PhD; Apostolos Papalois, MD, PhD; Gregorios Kouraklis, MD, PhD; Andreas Karabinis, MD, PhD; Theodosios Saranteas, MD, DDS, PhD; John Poularas, MD; John Papanikolaou, MD; Periklis Davlouros, MD, PhD; Nicos Labropoulos, MD, PhD; Dimitrios Karakitsos, MD, PhD


Crit Care Med. 2011;39(7):1607-1612. 

In This Article

Abstract and Introduction


Objective: Subclavian vein catheterization may cause various complications. We compared the real-time ultrasound-guided subclavian vein cannulation vs. the landmark method in critical care patients.
Design: Prospective randomized study.
Setting: Medical intensive care unit of a tertiary medical center.
Patients: Four hundred sixty-three mechanically ventilated patients enrolled in a randomized controlled ISRCTN-registered trial (ISRCTN-61258470).
Interventions: We compared the ultrasound-guided subclavian vein cannulation (200 patients) vs. the landmark method (201 patients) using an infraclavicular needle insertion point in all cases. Catheterization was performed under nonemergency conditions in the intensive care unit. Randomization was performed by means of a computer-generated random-numbers table and patients were stratified with regard to age, gender, and body mass index.
Measurements and Main Results: No significant differences in the presence of risk factors for difficult cannulation between the two groups of patients were recorded. Subclavian vein cannulation was achieved in 100% of patients in the ultrasound group as compared with 87.5% in the landmark one (p < .05). Average access time and number of attempts were significantly reduced in the ultrasound group of patients compared with the landmark group (p < .05). In the landmark group, artery puncture and hematoma occurred in 5.4% of patients, respectively, hemothorax in 4.4%, pneumothorax in 4.9%, brachial plexus injury in 2.9%, phrenic nerve injury in 1.5%, and cardiac tamponade in 0.5%, which were all increased compared with the ultrasound group (p < .05). Catheter misplacements did not differ between groups. In this study, the real-time ultrasound method was rated on a semiquantitative scale as technically difficult by the participating physicians.
Conclusions: The present data suggested that ultrasound-guided cannulation of the subclavian vein in critical care patients is superior to the landmark method and should be the method of choice in these patients. (Crit Care Med 2011; 39:1607–1612)


Central venous catheters play an important role in patient care, especially in the intensive care unit (ICU); however, their use is associated with various complications, even death.[1–5] Mechanical complications occur more frequently through the subclavian vein (SCV) route if compared with the internal jugular vein (IJV) and to the femoral vein routes.[6,7] Real-time, ultrasound-guided central venous cannulation results in a lower technical failure rate (overall and on first attempt), faster access, and a reduction in mechanical complications; nevertheless, this has been validated mainly for the IJV in previous reports.[8,9] Ultrasound-assisted location of the vein has been reported to have no effect on the rate of complications or failures of SCV catheterization in previous reports.[6] Most ultrasound studies of SCV catheterization used Doppler or "mark and go" techniques and not real-time (two-dimensional) ultrasound guidance.[10,11] Our team has previously demonstrated the superiority of the ultrasound-guided IJV cannulation as compared with the land mark method in critical care patients.[9] Furthermore, in our ICU, the overall rate of mechanical complications after "blind" SCV cannulation was approximately 15.8% out of 1000 catheterizations performed annually (unpublished data 2000–2005), which provided a clinical rationale for the present study. Hence, we compared the real-time ultrasound-guided approach with the landmark technique in the routine cannulation of the SCV in mechanically ventilated patients.