The intensive care unit of our facility is currentlyCentral venous catheter placementはThe internal jugular vein is the first choice.Regarding catheter replacement due to complications,Contralateral internal jugular vein and femoral veinThus, the subclavian vein is generally avoided due to the incidence and severity of mechanical complications, and the number of subclavian venous catheterizations is small. With the widespread use of real-time ultrasound-guided puncture and an increasing number of adequately trained operators,It is possible that the insertion of subclavian veins will become more widespread in the future, leading to a reduced risk of complications such as infection and thrombosis.There is.
Site-specific complications of central venous catheterization under systematic ultrasound guidance: a target trial emulation revisiting the 3SITES studyRandomized Controlled Trial. Nicolas Boulet et al; 3SITES Study Group.
Crit Care. 2025 Dec 2;29(1):513.
[Background] Central venous catheterization is the most frequently performed invasive procedure in the intensive care unit (ICU) but still carries risks of infection, thrombosis, and mechanical complications. Currently, real-time ultrasound-guided techniques are widely used, but it remains unclear how this method affects differences in complication rates among catheter insertion sites. The past "3SITES trial" showed that insertion via the subclavian vein reduces the risk of infection and thrombosis while increasing the risk of mechanical complications. However, ultrasound guidance was used in only one-third of this trial.
[Hypothesis] If real-time ultrasound guidance is used for all catheter insertions, the difference in complication rates between insertion sites (internal jugular vein, femoral vein, subclavian vein) will disappear.
[Objective] To compare the incidence of complications among three insertion sites (internal jugular vein, femoral vein, and subclavian vein) within a framework assuming all catheter insertions were performed under real-time ultrasound guidance.
[Methods] Post-analysis using the 3SITES trial dataset by a method called "target trial emulation." Inverse probability weighting (IPW) was applied to adjust for confounding factors affecting the choice of insertion site and the use of ultrasound guidance. The primary endpoint was the time to the first occurrence of either catheter-related bloodstream infection or symptomatic deep vein thrombosis.
[Results] A total of 3409 catheters (1153 femoral vein, 1267 internal jugular vein, 989 subclavian vein) were analyzed.
- The subclavian vein had a significantly lower incidence of the primary outcome (infection or symptomatic thrombosis) compared to the femoral vein (P = 0.02) and internal jugular vein (P = 0.001).
- There was no significant difference in the incidence of major outcomes between the internal jugular vein and femoral vein (P = 0.97).
- Catheter-related bloodstream infections were significantly fewer in the subclavian vein compared to the internal jugular vein (P = 0.001).
- Asymptomatic thrombosis occurred more frequently in the femoral and internal jugular veins.
- Major mechanical complications were rare overall, and no significant differences were observed between the three insertion sites.
[Consideration] Even with the assumption that ultrasound guidance was used in all cases, contrary to the authors' initial hypothesis, the difference in infection and thrombosis risk between sites remained, demonstrating the superiority of the subclavian vein. On the other hand, the incidence of major mechanical complications was significantly lower than in previous studies, and the difference between sites was eliminated. This suggests that the widespread introduction of ultrasound guidance has improved procedural safety, and the risk of mechanical complications, which was a major barrier to the subclavian approach, has now been offset.
[Conclusion] Assuming all central venous catheterizations are performed under real-time ultrasound guidance, the subclavian vein approach maintained a lower risk of infection and thrombosis without an increase in mechanical complications, supporting its preferential use in the ICU.
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