a b s t r a c t

Background: In this meta-analysis, we investigated the success rate of subclavian venous catheterization (SVC) as well as the incidence of related complications when performed via the supraclavicular (SC) or traditional infraclavicular (IC) approaches.

Methods: Ignoring the original language, we identified and analyzed eight Randomized controlled trials published on or before December 30, 2018, after searching the following five bibliographic databases: PubMed, Springer, Medline, EMBASE, and the Cochrane Library. All included studies compared the clinical safety and effi- ciency of the SC and IC approaches for SVC in adults. The Cochrane Collaboration’s Risk of Bias Tool was used to evaluate the methodological quality of each RCT. Cannulation Failure rates and the incidence of malposition were regarded as the primary outcome measures. Secondary outcome measures included cannulation access time and the Incidence of pneumothorax and artery puncture.

Results: Failure rates were significantly lower for SVC via the SC approach than via the IC approach [odds ratio, 0.66; 95% confidence interval (CI), 0.47 to 0.93]. The SC approach was also associated with a decreased incidence of catheter malposition, relative to that observed for the IC approach [odds ratio, 0.24; 95% CI, 0.13 to 0.46]. The SC approach did not reduce the time required for cannulation [mean difference, -74.74; 95% CI, -157.80 to 8.33], and there were no differences in the incidence of artery puncture [odds ratio, 0.60; 95% CI, 0.29 to 1.23] or pneu- mothorax [odds ratio, 0.89; 95% CI, 0.33 to 2.40].

Conclusion: Our findings suggest that SVC via the SC approach should be utilized in adults.

(C) 2020 The Author(s). This is an open access article under the CC BY-NC-ND license

(http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction

central venous catheterization is necessary during volume resuscita- tion, the administration of potent vasoactive drugs, hemodialysis, transvenous cardiac pacing, for patients with cancer in whom venous ac- cess has proven difficult, and for long-term chemotherapy [1,2]. There are three main large venous routes for central line insertion (i.e., internal jugular, subclavian, femoral), each with its own advantages, disadvantages, and potential complications [3,4]. Although ultrasound has been shown to increase the success rate of central venous access and to reduce related complications, it remains important for physicians to gain rapid and accu- rate vascular access without the use of ultrasound [5,6]. Advantages of sub- clavian venous catheterization (SVC) include a decreased risk of infection and thrombosis when compared with internal jugular or femoral sites and reduced patient discomfort, especially among those receiving long- term intravenous therapy (e.g., hyperalimentation, chemotherapy) [7].

* Corresponding author at: Department of Anesthesiology, Chongqing University Cancer Hospital/Chongqing Cancer Institute/Chongqing Cancer Hospital, 181# Hanyu Road, Shapingba District, Chongqing 400030, China.

E-mail address: [email protected] (B. Yang).

Moreover, the infraclavicular (IC) approach has been associated with a high incidence of complications such as subclavian artery puncture, pneumo- and hemothorax, and malposition [8]. The SC approach proposed by Yoffa et al. [9] relies on an identifiable somatic landmark (the clavisternomastoid angle), decreasing the distance from the skin to the vein. In addition, this approach provides a more direct route to the superior vena cava, better avoids the lung, and is associated with lower rates of complications such as arterial or pleural puncture. Nevertheless, it remains controversial whether subclavian vein puncture via the SC approach ex- hibits advantages relative to the IC approach, and the SC approach is used less frequently in clinical practice [10,11]. Thus, in the present study, we performed a meta-analysis of the scientific literature to compare the clinical safety and efficiency of the SC and IC approaches for SVC in adults which helped identify better practices for site selection in SVC.

Methods

Search strategy and selection criteria

Throughout the study, our meta-analysis adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)

https://doi.org/10.1016/j.ajem.2020.04.015

0735-6757/(C) 2020 The Author(s). This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Fig. 1. PRISMA flow diagram. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

guidelines [12]. The review methodology was registered at Prospero on November 13, 2018 (registration ID: CRD42018115002). We conducted a systematic, computerized search of the PubMed, EMBASE, Medline, Springer, and Cochrane databases. We used Boolean search terms

including “supraclavicular approach“, “Infraclavicular approach“, “sub- clavian vein catheterization”, “deep vein puncture”, and “vein access”. Controlled vocabularies (e.g., Medical Subject Heading terms) were used to identify synonyms. Furthermore, we checked the reference

Table 1

Trial characteristics.

Study	Year	No. patients	Selection of catheter	Gender	Time	Outcome
Dronen S [10]	1982	44/45	14 or 16 gauge	Both	Cardiopulmonary resuscitation	Failure rate of cannulation, malposition
Hussain S [11]	2011	72/72	16 or 18 gauge	Both	SICU	Failure rate of cannulation, number of attempts, complications
Momin AG [14]	2017	25/25	Unknown	Both	After anesthesia	(pneumothorax, artery, malposition) Access time, failure rate of cannulation, length of catheter and
						complications(pneumothorax, artery, malposition, arrhythmias)
Govindswamy [15]	2018	40/40	7FrG	Both	After anesthesia	Access time, success rate of cannulation, number of
Sterner S [16]	1986	245/255	16 gauge or 8 french	Both	Emergency	attempts, and complications (pneumothorax, artery, malposition) Failure rate of cannulation, catheter tip position, complications
Tarbiat M [17]	2018	140/140	18 gauge	Both	After anesthesia	(pneumothorax, artery, malposition) Failure rate of cannulation, number of attempts, complications
Thakur A [18]	2014	30/30	Unknown	Both	Before anesthesia	(pneumothorax, artery, malposition) Access time, failure rate of cannulation, number of attempts,
						complications (pneumothorax, artery)
Kocum A [19]	2011	65/65	7FrG	Both	After anesthesia	Failure rate of cannulation, number of attempts, complications (pneumothorax, artery, malposition)

1: Control group/Dexamethasone group; 2: Timing of TAP block relative to Surgery; 3:PONV: Postoperative nausea and vomiting; 4: DXM: Dexamethasone.

Fig. 2. Evaluation of risk of bias for each included study. Green circle indicates low risk of bias, red circle indicates high risk of bias, yellow circle indicates unclear risk of bias.

lists of all included studies and relevant reviews identified by our search. The search was performed on August 30, 2018 and updated on December 30, 2018. The including studies were limited to those pub- lished in English only.

Trial selection

Two authors (Q.C. and Q.L.) independently established study eligibil- ity. The decision was made based on consensus between these two au- thors. The opinion of a third author (B.Y.) was acquired when agreement could not be reached. The results of the trial selection pro- cess are presented in the PRISMA flowchart (Fig. 1).

Outcome measures

Overall cannulation failure rates and the incidence of malposition were regarded as the primary outcome measures. Secondary outcome measures included cannulation access time and the incidence of pneu- mothorax and artery puncture.

Study characteristics and data extraction

The following characteristics were extracted: name of the principal author, Publication year, sex, number of patients in each group, timing of the procedure, and catheter size. We also collected data regarding cannulation failure rates, catheter malposition, access time, and compli- cations (Table 1). The data were independently extracted by two

authors (Q.C. and Q.L.), and discrepancies were resolved through review and discussion. Data were extracted if the mean, standard deviation (SD), and number of patients (n) were reported or could be calculated. We emailed the authors to request additional data when necessary.

Study quality and risk-of-Bias assessment

The quality of each RCT was assessed separately by two authors (Q.C. and Q.L.) using the Cochrane Collaboration Risk of Bias Tool [13]. Vari- ous types of bias (e.g., selection, performance, detection, attrition, reporting, and other forms) were used to evaluate RCTs (Fig. 2). A qual- ity score was generated for each RCT via consensus between the two au- thors, and a third author (B.Y.) resolved any disagreements. RCT quality scores were not a key factor for trial exclusion.

Statistical analysis

All data analyses were performed using Review Manager 5.3 soft- ware (Cochrane Collaboration, Oxford, UK). Continuous data (access time) are expressed as the mean difference (MD) or SMD and the 95% confidence interval (CI). Dichotomous data (cannulation failure rate, catheter malposition, incidence of artery puncture/pneumothorax) are expressed as odds ratios (OR) and 95% CIs. Heterogeneity was evaluated using the ?2 test (P-value and I² value). A random effects model was se- lected in cases of heterogeneity (P b 0.1 or I² >= 50%), while a fixed effects model was selected in cases of homogeneity (P >= 0.1 or I² b 50%).

Fig. 3. The failure rate of cannulation between SC and IC approach for SVC.

Fig. 4. The incidence of malposition of catheter between SC and IC approach for SVC.

Publication bias was analyzed using the Egger test, for which P N 0.05 in- dicated a lack of statistically significant publication bias.

Results

Study selection and characteristics

A total of eight qualifying RCTs involving 1333 adults (Fig. 1) were identified [10,11,14-19]. The characteristics of patients and interven- tions are summarized in Table 1. All eight RCTs compared the clinical safety and efficiency of the SC and IC approaches for SVC. In all included studies, SVC was performed via a right approach using the landmark method, in order to ensure that the results were not affected by differ- ences in puncture site or method.

Cannulation failure rate

All included studies reported the cannulation failure rate (n = 1333), which was defined as more than three attempts at catheteriza- tion [10,11,14-19]. Cannulation failure rates were lower for the SC ap- proach than for the IC approach (95% CI, 0.47 to 0.93; I² = 21%; P = 0.02) (Fig. 3). Implementing sensitivity analyses and Egger tests for publication bias did not significantly alter these results (P = 0.133).

Catheter malposition

Seven of the eight included studies (n = 1273) measured the posi- tion of the catheter tip after catheterization [10,11,14-17,19]. The inci- dence of catheter malposition was 5% lower for the SC approach than for the IC approach (95% CI, 0.13 to 0.46; I² = 24%; P b 0.00001) (Fig. 4). Implementing sensitivity analyses and Egger tests for publica- tion bias did not significantly alter these results (P = 1.00).

Access time

Four RCTs (n = 320) investigated the time required for SVC using the two approaches [14,15,18,19]. On average, the SC approach for SVC reduced operation time by 74.74 s (95% CI, -157.8 to 7.33; I² = 95%; P = 0.08; IC baseline, 328.75 s). However, this difference was not statistically significant (Fig. 5).

Artery puncture and pneumothorax

Puncture-related complications of SVC were recorded in seven RCTs (n = 1244) [11,14-19]. Our analysis revealed no significant differences in the incidence of pneumothorax (95% CI, 0.33 to 2.40; I² = 0%; P = 0.82) (Fig. 6) or artery puncture (95% CI, 0.29 to 1.23; I² = 0%; P = 0.16) between the SC and IC approaches (Fig. 7). Implementing sensitiv- ity analyses and Egger tests for publication bias did not significantly alter these results (P = 1.00 for pneumothorax and P = 0.308 for artery puncture).

Discussion

The present study is, to the best of our knowledge, the first meta- analysis to compare the clinical safety and efficiency of the SC and IC ap- proaches for SVC in adults. After analyzing the comprehensive results of eight RCTs, we determined that the SC approach is associated with lower rates of cannulation failure and catheter malposition than the IC approach. However, there were no significant differences in the inci- dence of artery puncture/pneumothorax or access time between the two groups.

The subclavian vein is preferred for central venous catheterization due to easy insertion, greater diameter, lower complication rates, and a higher level of patient acceptance [20]. Moreover, subclavian vein can- nulation is associated with a lower risk of catheter-related infection and thrombosis than femoral or internal jugular vein cannulation [7].

Fig. 5. The access time of catheteration between SC and IC approach for SVC.

Fig. 6. The incidence of artery puncture between SC and IC approach for SVC.

However, SC catheterization is performed much less frequently than IC catheterization. It may be a misconception that central vein catheteriza- tion access from over the clavicle presents a greater risk to the patient [21]. Moreover, some studies have suggested that subclavian venipunc- ture via the SC approach leads to a higher incidence of pneumothorax and artery puncture [11,15]. In contrast to these reports, we observed no significant differences in rates of mechanical complications between the SC approach and the traditional IC approach.

We also observed no significant differences in operation duration between the SC and IC approaches. As previously mentioned, the SC ap- proach is more accurate and more direct than the IC approach. Vezzani and Yamamoto have confirmed that subclavian venipuncture via the SC approach is more superficial and allows for easier access than the IC ap- proach, even with ultrasound guidance [22,23]. Taken together, these findings still suggest that the SC approach should be used when rapid venous access is required.

Several reports have indicated that subclavian venipuncture via the SC approach is useful in various clinical settings. Bojic reported that SC access to the right subclavian vein is a useful alternative for placing ex- tracorporeal membrane oxygenation (ECMO) cannulae with low rates of complications, good tolerance, and performance comparable to stan- dard right jugular cannulation [24]. Liu and Laczika further noted that pacing through the right supraclavicular vein is safe and reliable, with low complication rates [25,26]. Byon and Rhondali also demonstrated that the ultrasound-guided SC approach for subclavian vein puncture can be used for central venous catheterization in small infants and chil- dren, offering all the advantages of subclavian vein cannulation without the risk of ‘pinch-off’ syndrome [27,28]. The right approach was chosen in all included studies, as previous studies have confirmed that the left SC approach increases the risk of mistakenly injuring the thoracic duct

[23,29]. Nonetheless, physicians should attempt to avoid the left SC ap- proach in clinical settings.

Our meta-analysis had several limitations of note. First, in this study, all individuals were adults, and SC puncture is primarily used in chil- dren. As deep subclavian vein puncture via the SC approach is utilized less frequently among children, further studies regarding this technique are required. Second, ultrasound-guided subclavian venipuncture was not examined in this study. Future studies should aim to clarify the ef- fect of ultrasound guidance on the success and complication rates of subclavian venipuncture. Third, the RCTs included in our study failed to embody the principle of double blindness, as this was impossible due to comparisons among different clinical operations.

Conclusion

In conclusion, our meta-analysis demonstrates that the SC approach is advantageous relative to the IC approach in terms of operation dura- tion and success rate, with no increases in the rate of related complica- tions. Our findings suggest that SVC via the SC approach should be utilized in adult patients in routine scenarios. Further studies are re- quired to determine the potential applications of ultrasound for the SC approach.

Declaration of funding

This work was supported by Basic science and advanced technology foundation of Chongqing Science and Technology Commission (cstc2016jcyjA0158 to Bin Yang) and Foundation of Chongqing Health and Family Planning Commission (ZY201702036 to Bin Yang) and Foundation and Frontier Research Projects of Chongqing Science and

Fig. 7. The incidence of pneumothorax between SC and IC approach for SVC.

Technology Commission(cstc2018jxjl130028 to Bin Yang) and Scien- tific and Technological Research Program of Chongqing Municipal Edu- cation Commission (KJQN201800104 to Qi Chen).

Author contributions

Data curation: Qin Long, Tan-xiao Tang. Formal analysis: Qi Chen, Qin Long.

Funding acquisition: Bin Yang, Qi Chen Methodology: Jingqiu Liang, Qin Long. Project administration: Bin Yang.

Supervision: Bin Yang. Visualization: Tan-xiao Tang.

Writing – original draft: Qi Chen, Qin Long, Jingqiu Liang Writing – review & editing: Qi Chen, Bin Yang.

Declaration of competing interest

The authors report no conflicts of interest in this work.

References

1. Tejedor SC, Tong D, Stein J, et al. Temporary central venous catheter utilization pat- terns in a large tertiary care center: tracking the “idle central venous catheter”. Infect Control Hosp Epidemiol 2012;33:50-7.
2. Tarbiat M, Manafi B, Davoudi M, et al. Comparison of the complications between left side and right side subclavian vein catheter placement in patients undergoing coro- nary artery bypass graft surgery. J Cardiovasc Thorac Res 2014;6:147-51.
3. Parienti J-J, Thirion M, Megarbane B, et al. Femoral vs jugular venous catheterization and risk of nosocomial events in adults requiring acute renal replacement therapy: a randomized controlled trial. JAMA 2008;299:2413-22.
4. Merrer J, De Jonghe B, Golliot F, et al. Complications of femoral and subclavian ve- nous catheterization in critically ill patients: a randomized controlled trial. JAMA 2001;286:700-7.
5. Wu SY, Ling Q, Cao LH, et al. Real-time two- dimensional ultrasound guidance for central venous cannulation: a meta-analysis. Anesthesiology 2013;118:361-75.
6. Aouad MT, Kanazi GE, Abdallah FW, et al. Femoral vein cannulation performed by residents: a comparison between ultrasound-guided and landmark technique in in- fants and children undergoing cardiac surgery. Anesth Analg 2010;111:724-8.
7. Parienti JJ, Mongardon N, Megarbane B. Intravascular complications of central ve- nous catheterization by insertion site. N Engl J Med 2015;373:1220-9.
8. McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med 2003;348:1123-33.
9. Yoffa D. Supraclavicular subclavian venipuncture and catheterisation. Lancet 1965;2:

   614-7.

   Dronen S, Thompson B, Nowak R. subclavian vein catheterization during cardiopul- monary resuscitation. A prospective comparison of the supraclavicular and infraclavicular percutaneous approaches. JAMA 1982;18(247):3227-30.

10. Hussain S, Khan RA, Iqbal M, Shafiq M. A comparative study of supraclavicular versus infraclavicular approach for central venous catheterization. Anaesth Pain Intensive Care 2011;15(1):13-6.
11. Shamseer L, Moher D, Clarke M, et al. Preferred reporting items for systematic re- view and meta-analysis protocols (PRISMA-P) 2015: elaboration and explanation. BMJ 2015;350:g7647.
12. Higgins JP, Altman DG, Gotzsche PC, Cochrane Statistical Methods Group, et al. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. Br Med J 2011;343:d5928.
13. Momin AG, Priti M, Madhuri A, et al. Comparative evaluation of subclavian vein catheterization using supraclavicular versus infraclavicular approach. Indian J Anaesth 2017;4:26-9.
14. Govindswamy S, Shamanna AM, Gowda P. Comparison between supraclavicular and infraclavicular approaches for subclavian venous catheterization in adults. Sri Lankan J Anaesthesiol 2018;26:34-8.
15. Sterner S, Plummer DW, Clinton J, et al. A comparison of the supraclavicular ap- proach and the infraclavicular approach for subclavian vein catheterization. Ann Emerg Med 1986;15:421-4.
16. Tarbiat M, Farhanchi A, Davoudi M, et al. Supraclavicular versus infraclavicular sub- clavian vein catheterization in Coronary artery bypass graft surgery. Res Cardiovasc Med 2018;7:5-9.
17. Thakur A, Kaur K, Lamba A, et al. Comparative evaluation of subclavian vein cathe- terisation using supraclavicular versus infraclavicular approach. Indian J Anaesth 2014;58:160-4.
18. Kocum A, Sener M, Caliskan E, et al. An alternative central venous route for cardiac surgery: supraclavicular subclavian vein catheterization. J Cardiothorac Vasc Anesth 2011;25:1018-23.
19. Parienti JJ, du Cheyron D, Timsit JF, et al. Meta-analysis of subclavian insertion and nontunneled central venous catheter-associated Infection risk reduction in critically ill adults. Crit Care Med 2012;40 1627-163.
20. Czarnik T, Gawda R, Perkowski T, et al. Supraclavicular approach is an easy and safe method of subclavian vein catheterization even in Mechanically ventilated patients: analysis of 370 attempts. Anesthesiology 2009;111:334-9.
21. Vezzani A, Manca T, Brusasco C, et al. A randomized clinical trial of ultrasound- guided infra-clavicular cannulation of the subclavian vein in cardiac surgical pa- tients: short-axis versus long-axis approach. Intensive Care Med 2017;43: 1594-601.
22. Yamamoto T, Schindler E. Real-time ultrasound-guided right supraclavicular ap- proach to the central vein: an alternative option. Anesth Analg 2017;125:359.
23. Bojic A, Steiner I, Gamper J. Supraclavicular approach to the subclavian vein as an al- ternative venous access site for ECMO cannulae? A retrospective comparison. ASAIO J 2017;63:679-83.
24. Liu KS, Liu C, Xia Y, et al. Permanent cardiac pacing through the right supraclavicular subclavian vein approach. Can J Cardiol 2003;19:1005-8.
25. Laczika K, Thalhammer F, Locker G, et al. Safe and efficient emergency transvenous ventricular pacing via the right supraclavicular route. Anesth Analg 2000;90:784-9.
26. Byon HJ, Lee GW, Lee JH, et al. Comparison between ultrasound- guided supraclavicular and infraclavicular approaches for subclavian venous catheterization in children – a randomized trial. Br J Anaesth 2013;111:788-92.
27. Rhondali O, Attof R, Combet S, et al. Ultrasound-guided subclavian vein cannulation in infants: supraclavicular approach. Paediatr Anaesth 2011;21:1136-41.
28. Tarbiat M, Manafi B, Davoudi M, Totonchi Z. Comparison of the complications between left side and right side subclavian vein catheter placement in patients undergoing coronary artery bypass graft surgery. J Cardiovasc Thorac Res 2014; 6:147-51.