Intravascular Complications of Central Venous Catheterization by Insertion Site
Intravascular Complications of Central Venous Catheterization by Insertion Site.
New England Journal of Medicine 373;13.
Jean‑Jacques Parienti, M.D., Ph.D., et al for the 3SITES Study Group*
The Idea: Central venous catheterization is a frequent procedure in the critically ill patients. The three sites for CVC placement have been evaluated with respect to complications and this anatomical study attempted to evaluate the safest route of access.
The Study: This was a multicenter, randomized trial in multiple intensive care units in France. Over 3000 patients were included in the study with a total of 3471 catheters in the analysis. Patients were randomized in a 1:1:1 fashion for the placement of CVC in the femoral, IJ and subclavian veins if all sites were accessible. If only 2 sites were accessible, the placement was randomized in a 1:1 fashion, and if only one site was available, the data was not included. Primary outcome measure was the development of catheter-related bloodstream infections and development of symptomatic DVT. Secondary outcome measures included mechanical complications of the catheterization.
The Results: 3471 catheters were included in the statistical analysis from 3027 patients. The primary outcomes of catheter related infection and DVT were higher in the femoral group compared to the subclavian group and in the jugular group than the subclavian group. The risk of primary outcomes in the femoral group was similar to the risks in the jugular group. The risk of secondary outcomes, primarily pneumothorax was highest in the subclavian group in which 1.5% of subclavian CVC were associated with the need for chest tube placement for iatrogenic pneumothorax whereas 0.5% of internal jugular CVCs requred chest tube placement.
The Takeaway: According to this study, subclavian vein catheterization was associated with the fewest primary outcomes but had the highest risk for secondary outcomes. Essentially, the site for CVC placement should be driven by not only the primary and secondary outcomes, but the comfort level of the physician. If the physician performing the procedure is not comfortable placing a subclavian in a critically ill patient, this is not a good option as the development of a pneumothorax with subsequent chest tube placement, in a critically ill patient, is potentially a life threatening complication that can be avoided. Although the development of DVT is lower in the subclavian group, DVTs in the subclavian vein carry significantly higher morbidity due to the lack of collateral circulation and patients can go on to have life long, debilitating edema of the affected extremity. Based on this data, it is again up to the discretion of the physician to decide which risk factors, and chronic sequelae of said risk factors, are of more concern. If catheter-related infection is of most concern, subclavian is the statistically superior option. If avoidance of pneumothorax is paramount, femoral placement is superior.