Majo D . Bimal Ahluwalia, e al. Ul asound-Guided Ve sus Landma k-Based Subcla ian Vein Ca he e iza ion: A
Te ia y Ca e Cen e Expe ience. In . J Med. Pha m. Res., 6 (6): 504‐513, 2025
504
In e na ional Jou nal o Medical
and Pha maceu ical Resea ch
Online ISSN-2958-3683 | P in ISSN-2958-3675
F equency: Bi-Mon hly
A ailable online on: h ps://ijmp .in/
Resea ch A icle
Ul asound-Guided Ve sus Landma k-Based Subcla ian Vein
Ca he e iza ion: A Te ia y Ca e Cen e Expe ience
Majo D . Bimal Ahluwalia, MBBS, MD (Anaes hesiology), FCARCSI (UK)
SAG Specialis , Anaes hesiology, Indi a Gandhi Hospi al, Sec o 9, Dwa ka, New Delhi – 110077
A B S T R A C T
Co esponding Au ho :
Majo D . Bimal Ahluwalia
SAG Specialis , Anaes hesiology,
Indi a Gandhi Hospi al, Sec o 9,
Dwa ka, New Delhi – 110077
Recei ed: 15‐10‐2025
Accep ed: 13‐11‐2025
A ailable online: 18‐11‐2025
Backg ound: Cen al enous ca he e iza ion h ough he subcla ian ein emains
a undamen al p ocedu e in c i ical ca e and pe iope a i e managemen . While he
landma k-based echnique has been he adi ional app oach, ul asound guidance
has eme ged as a po en ially sa e al e na i e. Howe e , compa a i e da a om
e ia y ca e se ings emain limi ed. This s udy aimed o compa e he e icacy and
sa e y o ul asound-guided e sus landma k-based subcla ian ein
ca he e iza ion.
Me hods: This compa a i e obse a ional s udy was conduc ed a a e ia y ca e
cen e om June 2024 o July 2025. A o al o 200 pa ien s equi ing subcla ian
cen al enous access we e en olled and alloca ed in o wo g oups: ul asound-
guided (n=100) and landma k-based (n=100) echniques. P ima y ou comes
included i s -a emp success a e, o e all success a e, and p ocedu al
complica ions. Seconda y ou comes comp ised p ocedu e ime, numbe o
a emp s, and pa ien sa is ac ion sco es. Da a we e analyzed using app op ia e
s a is ical es s wi h p<0.05 conside ed signi ican .
Resul s: The ul asound-guided g oup demons a ed signi ican ly highe i s -
a emp success a es compa ed o he landma k-based g oup (87% s 64%,
p<0.001). O e all success a es we e 98% and 91% espec i ely (p=0.021).
Complica ion a es we e signi ican ly lowe in he ul asound-guided g oup (8%
s 23%, p=0.003), pa icula ly a e ial punc u e (2% s 12%, p=0.006) and
pneumo ho ax (1% s 6%, p=0.048). Mean p ocedu e ime was sho e in he
ul asound-guided g oup (8.4±2.3 minu es s 11.2±3.8 minu es, p<0.001).
Conclusion: Ul asound-guided subcla ian ein ca he e iza ion demons a ed
supe io i s -a emp success a es, educed complica ions, and sho e p ocedu e
imes compa ed o he landma k-based echnique. These indings suppo he
adop ion o ul asound guidance as he p e e ed me hod o subcla ian cen al
enous access in e ia y ca e se ings.
Copy igh © In e na ional Jou nal o
Medical and Pha maceu ical Resea ch
Keywo ds: Subcla ian ein ca he e iza ion, ul asound guidance, landma k
echnique, cen al enous access, complica ions.
INTRODUCTION
Cen al enous ca he e iza ion ep esen s one o he mos commonly pe o med in asi e p ocedu es in mode n medical
p ac ice, wi h millions o ca he e s inse ed annually wo ldwide o di e se clinical indica ions including hemodynamic
moni o ing, adminis a ion o asoac i e medica ions, pa en e al nu i ion, hemodialysis, and long- e m in a enous
he apy. Among he a ious ana omical si es a ailable o cen al enous access, he subcla ian ein has his o ically been
a o ed by many clinicians due o i s ela i ely p edic able ana omy, ease o secu ing ca he e s, lowe in ec ion a es
compa ed o emo al access, and supe io pa ien com o du ing p olonged ca he e iza ion.(1) The subcla ian ou e also
o e s ad an ages in e ms o educed h ombo ic complica ions and g ea e pa ien mobili y, making i pa icula ly
a ac i e o c i ically ill pa ien s equi ing ex ended cen al enous access.
T adi ionally, subcla ian ein ca he e iza ion has been pe o med using he landma k-based echnique, which elies on
ex e nal ana omical landma ks such as he cla icle, s e num, and sup as e nal no ch o guide needle inse ion. This blind
app oach, i s desc ibed in he 1960s and e ined o e subsequen decades, has been he co ne s one o aining o
gene a ions o physicians and emains widely p ac iced ac oss heal hca e ins i u ions globally.(2) The in acla icula
Majo D . Bimal Ahluwalia, e al. Ul asound-Guided Ve sus Landma k-Based Subcla ian Vein Ca he e iza ion: A
Te ia y Ca e Cen e Expe ience. In . J Med. Pha m. Res., 6 (6): 504‐513, 2025
505
app oach, u ilizing he junc ion o he middle and medial hi ds o he cla icle as he inse ion si e wi h needle ajec o y
owa d he sup as e nal no ch, has become he mos commonly employed landma k-based me hod. P oponen s o his
adi ional echnique ci e i s simplici y, absence o equipmen equi emen s beyond s anda d ca he e iza ion ki s, and he
abili y o pe o m he p ocedu e apidly in eme gency si ua ions wi hou he need o specialized imaging equipmen .
Howe e , he landma k-based app oach is no wi hou signi ican limi a ions and po en ial haza ds. The echnique elies
hea ily on ope a o expe ience and ac ile eedback, wi h ana omical a ia ions, pa ien body habi us, p e ious su ge ies,
and pa hological condi ions po en ially al e ing he expec ed ascula ana omy and inc easing p ocedu al di icul y. The
blind na u e o he landma k echnique inhe en ly ca ies isks o mechanical complica ions, including a e ial punc u e,
pneumo ho ax, hemo ho ax, ne e inju y, ho acic duc inju y, and ca he e malposi ion. Published li e a u e has
documen ed mechanical complica ion a es anging om 5% o 19% wi h he landma k-based subcla ian app oach, wi h
pneumo ho ax occu ing in 1.5% o 6% o cases and a e ial punc u e in 3% o 12% o a emp s.(3) These complica ions
can esul in signi ican mo bidi y, p olonged hospi al s ays, inc eased heal hca e cos s, and in a e cases, mo ali y.
Fu he mo e, mul iple needle passes equi ed du ing di icul cannula ions no only inc ease complica ion isks bu also
cause pa ien discom o and anxie y, po en ially comp omising p ocedu al success.
The ad en o po able ul asound echnology has e olu ionized he app oach o ascula access p ocedu es, o e ing eal-
ime isualiza ion o ana omical s uc u es and dynamic needle guidance du ing ca he e inse ion. Ul asound-guided
cen al enous ca he e iza ion was ini ially adop ed o in e nal jugula ein access, whe e nume ous andomized con olled
ials and me a-analyses ha e consis en ly demons a ed supe io i y o e he landma k echnique in e ms o success a es,
educed complica ions, and ewe a emp s o success ul cannula ion.(4) The success o ul asound guidance in in e nal
jugula ca he e iza ion p omp ed p o essional socie ies, including he Na ional Ins i u e o Heal h and Ca e Excellence
(NICE) in 2002 and he Ame ican Socie y o Anes hesiologis s in 2012, o ecommend ul asound guidance as he p e e ed
me hod o cen al enous access when a ailable. These ecommenda ions ha e led o widesp ead adop ion o ul asound-
guided in e nal jugula ca he e iza ion as he s anda d o ca e in many de eloped heal hca e sys ems.
Despi e he p o en bene i s o ul asound guidance o in e nal jugula ein ca he e iza ion, he adop ion o ul asound
echnology o subcla ian ein access has been conside ably slowe and emains a subjec o ongoing deba e. Se e al
ac o s ha e con ibu ed o his delayed accep ance, including conce ns abou he s eep lea ning cu e associa ed wi h
ul asound-guided sup acla icula and in acla icula app oaches, he echnical challenges o isualizing subcla ian
ana omy due o acous ic shadowing om he cla icle, limi ed eal-es a e o p obe placemen in he in acla icula egion,
and he his o ical pe cep ion ha subcla ian ca he e iza ion is su icien ly sa e using he landma k echnique.(5)
Addi ionally, many aining p og ams con inue o emphasize landma k-based echniques, and ins i u ional p o ocols may
no manda e ul asound use o subcla ian access, unlike in e nal jugula ca he e iza ion whe e ul asound guidance has
become s anda d p ac ice in many cen e s.
Recen ad ances in ul asound echnology, including he de elopmen o high- equency linea p obes, imp o ed image
quali y, and he desc ip ion o no el app oaches such as he sup acla icula echnique, ha e ekindled in e es in
ul asound-guided subcla ian ein ca he e iza ion. Eme ging e idence sugges s ha ul asound guidance may o e simila
ad an ages o subcla ian access as demons a ed o in e nal jugula ca he e iza ion, including imp o ed i s -a emp
success a es, educed mechanical complica ions, and enhanced p ocedu al sa e y.(6) The sup acla icula app oach, in
pa icula , has gained popula i y as i allows excellen isualiza ion o he subcla ian-in e nal jugula junc ion wi h he
ul asound p obe posi ioned in he sup acla icula ossa, a oiding he acous ic shadowing challenges encoun e ed wi h
in acla icula p obe placemen . This echnique combines he bene i s o subcla ian ca he e iza ion wi h he isualiza ion
ad an ages o ul asound guidance, po en ially o e ing an op imal balance be ween sa e y and e icacy.
Se e al ecen s udies ha e in es iga ed he compa a i e ou comes o ul asound-guided e sus landma k-based subcla ian
ein ca he e iza ion, yielding p omising bu some imes con adic o y esul s. A sys ema ic e iew and me a-analysis by
B ass e al. demons a ed ha ul asound guidance o subcla ian ein ca he e iza ion signi ican ly educed he isk o
mechanical complica ions, pa icula ly pneumo ho ax and a e ial punc u e, while imp o ing i s -a emp success a es.(7)
Howe e , o he s udies ha e epo ed mo e modes bene i s o ha e highligh ed he impo ance o ope a o expe ience and
aining in de e mining ou comes wi h bo h echniques. The he e ogenei y in s udy designs, pa ien popula ions, ope a o
expe ise, and speci ic ul asound app oaches employed has made i challenging o d aw de ini i e conclusions abou he
supe io i y o one echnique o e he o he in all clinical con ex s.
In he con ex o de eloping coun ies and esou ce-limi ed se ings, he deba e su ounding ul asound-guided subcla ian
ca he e iza ion akes on addi ional dimensions. While ul asound machines ha e become inc easingly a o dable and
po able, hei a ailabili y in all clinical a eas whe e cen al enous access is equi ed emains a iable. T aining
oppo uni ies o ul asound-guided ascula access may be limi ed, and s anda dized p o ocols o eaching and
implemen ing his echnique a e o en lacking.(8) Fu he mo e, in eme gency si ua ions o when ul asound equipmen is
una ailable, clinicians mus main ain p o iciency in landma k-based echniques. These p ac ical conside a ions necessi a e
ongoing e alua ion o bo h app oaches and he de elopmen o ins i u ional guidelines ha accoun o local esou ces,
aining in as uc u e, and pa ien popula ions.
Majo D . Bimal Ahluwalia, e al. Ul asound-Guided Ve sus Landma k-Based Subcla ian Vein Ca he e iza ion: A
Te ia y Ca e Cen e Expe ience. In . J Med. Pha m. Res., 6 (6): 504‐513, 2025
506
The pa ien popula ion equi ing subcla ian cen al enous access in e ia y ca e cen e s is di e se and o en p esen s
unique challenges. C i ically ill pa ien s in in ensi e ca e uni s may ha e coagulopa hy, al e ed ana omy due o edema o
p e ious in e en ions, and mul iple como bidi ies ha inc ease p ocedu al isks. Oncology pa ien s equi ing long- e m
enous access may ha e h ombosed eins om p e ious ca he e iza ions o chemo he apy. T auma pa ien s may equi e
u gen access in challenging ci cums ances. Hemodialysis pa ien s o en ha e exhaus ed pe iphe al enous access and
equi e eliable la ge-bo e ca he e s. Each o hese pa ien popula ions may bene i di e en ly om ul asound-guided
e sus landma k-based app oaches, and unde s anding hese nuances is essen ial o op imizing ou comes.(9)
The lea ning cu e associa ed wi h ul asound-guided subcla ian ca he e iza ion ep esen s ano he impo an
conside a ion. While some s udies sugges ha compe ency can be achie ed wi h a ela i ely modes numbe o supe ised
p ocedu es, o he s indica e ha subs an ial expe ience is equi ed o consis en ly achie e success a es compa able o o
be e han expe ienced ope a o s using he landma k echnique.(10) The op imal aining me hodology, including he ole
o simula ion, he numbe o supe ised p ocedu es equi ed, and he assessmen o compe ency, emains an a ea o ac i e
in es iga ion. Ins i u ions con empla ing he adop ion o ul asound-guided subcla ian ca he e iza ion mus conside hese
aining equi emen s and de elop comp ehensi e educa ional p og ams o ensu e success ul implemen a ion.
Gi en he ongoing deba e ega ding he op imal echnique o subcla ian ein ca he e iza ion, he a iabili y in published
da a, and he limi ed e idence om e ia y ca e se ings in de eloping coun ies, he e exis s a clea need o addi ional
compa a i e s udies ha e alua e bo h echniques unde eal-wo ld clinical condi ions wi h di e se pa ien popula ions.
Unde s anding he ela i e ad an ages and disad an ages o ul asound-guided e sus landma k-based subcla ian
ca he e iza ion in e ms o success a es, complica ion p o iles, p ocedu e imes, and pa ien ou comes is essen ial o
de eloping e idence-based guidelines and imp o ing he sa e y and e icacy o his common p ocedu e. This s udy was
unde aken o add ess hese knowledge gaps and p o ide con empo a y compa a i e da a om a e ia y ca e cen e
expe ience, wi h he goal o in o ming clinical p ac ice and con ibu ing o he ongoing e olu ion o bes p ac ices in cen al
enous ca he e iza ion.
AIMS AND OBJECTIVES
The p ima y aim o his s udy was o compa e he e icacy and sa e y o ul asound-guided e sus landma k-based
echniques o subcla ian ein ca he e iza ion in pa ien s equi ing cen al enous access a a e ia y ca e cen e . The s udy
was designed o e alua e whe he ul asound guidance o e ed measu able ad an ages in e ms o p ocedu al success and
complica ion a es compa ed o he adi ional landma k-based app oach in ou ine clinical p ac ice.
The p ima y objec i es o his s udy we e o compa e he i s -a emp success a es be ween ul asound-guided and
landma k-based subcla ian ein ca he e iza ion and o assess he o e all success a es o bo h echniques. The s udy also
aimed o e alua e he incidence and ypes o mechanical complica ions associa ed wi h each app oach, including a e ial
punc u e, pneumo ho ax, hemo ho ax, hema oma o ma ion, and ca he e malposi ion.
The seconda y objec i es included compa ing he mean p ocedu e ime om skin punc u e o success ul guidewi e
placemen be ween he wo g oups, analyzing he numbe o needle inse ion a emp s equi ed o success ul
ca he e iza ion, and e alua ing pa ien sa is ac ion and discom o sco es associa ed wi h each echnique. The s udy u he
aimed o iden i y pa ien - ela ed and p ocedu e- ela ed ac o s ha in luenced success a es and complica ion p o iles in
bo h g oups, including body mass index, p esence o ana omical a ia ions, ope a o expe ience, and u gency o he
p ocedu e. Addi ionally, he s udy sough o assess he easibili y and p ac icali y o implemen ing ou ine ul asound
guidance o subcla ian ein ca he e iza ion in a e ia y ca e se ing wi h di e se pa ien popula ions and a ying le els o
ope a o expe ience.
MATERIALS AND METHODS
S udy Design and Se ing
This compa a i e obse a ional s udy was conduc ed in he Depa men o Anes hesiology and C i ical Ca e a a e ia y
ca e eaching hospi al om June 2024 o July 2025. The s udy was app o ed by he Ins i u ional E hics Commi ee, and
w i en in o med consen was ob ained om all pa ien s o hei legal ep esen a i es p io o en ollmen . The s udy adhe ed
o he Decla a ion o Helsinki guidelines and good clinical p ac ice p inciples.
Sample Size Calcula ion
The sample size was calcula ed based on p e iously published li e a u e epo ing i s -a emp success a es o
app oxima ely 85% o ul asound-guided and 65% o landma k-based subcla ian ca he e iza ion. Using a powe o 80%,
alpha e o o 0.05, and accoun ing o a 10% d opou a e, a minimum o 92 pa ien s pe g oup was equi ed. The s udy
en olled 100 pa ien s in each g oup o ensu e adequa e s a is ical powe .
Pa ien Selec ion
Pa ien s aged 18 yea s and abo e equi ing subcla ian cen al enous ca he e iza ion o a ious clinical indica ions
including hemodynamic moni o ing, adminis a ion o asoac i e d ugs, pa en e al nu i ion, hemodialysis, o long- e m
Majo D . Bimal Ahluwalia, e al. Ul asound-Guided Ve sus Landma k-Based Subcla ian Vein Ca he e iza ion: A
Te ia y Ca e Cen e Expe ience. In . J Med. Pha m. Res., 6 (6): 504‐513, 2025
507
in a enous he apy we e conside ed o en ollmen . Pa ien s we e alloca ed o ei he he ul asound-guided g oup o he
landma k-based g oup based on he a ailabili y o ained pe sonnel and ul asound equipmen a he ime o p ocedu e,
ensu ing a non- andomized bu consecu i e alloca ion pa e n.
Inclusion C i e ia
The inclusion c i e ia comp ised adul pa ien s aged 18 yea s and abo e who equi ed subcla ian cen al enous
ca he e iza ion o alid clinical indica ions, pa ien s who p o ided in o med consen o whose legal ep esen a i es
consen ed on hei behal , pa ien s wi h bo h elec i e and eme gency indica ions o cen al enous access, and pa ien s
unde going hei i s subcla ian ca he e iza ion a emp du ing he cu en hospi al admission.
Exclusion C i e ia
Pa ien s we e excluded i hey had known ana omical abno mali ies o he subcla ian egion including p e ious su ge ies,
adia ion he apy, o congeni al mal o ma ions. O he exclusion c i e ia included se e e coagulopa hy wi h in e na ional
no malized a io g ea e han 2.0 o pla ele coun less han 50,000 pe mic oli e ha could no be co ec ed p io o he
p ocedu e, local in ec ion a he p oposed inse ion si e, p e ious ailed subcla ian ca he e iza ion a emp s du ing he
cu en admission, pa ien s equi ing eme gency ca he e iza ion when ul asound equipmen o ained pe sonnel we e
una ailable o he ul asound-guided g oup, pneumo ho ax o hemo ho ax on he ipsila e al side, supe io ena ca a
synd ome, and pa ien s who e used consen o we e unable o p o ide consen wi hou legal ep esen a i es.
P ocedu al Technique
All p ocedu es we e pe o med by anes hesiologis s o c i ical ca e physicians wi h a leas wo yea s o expe ience in
cen al enous ca he e iza ion. Ope a o s in he ul asound-guided g oup had comple ed a minimum o 20 supe ised
ul asound-guided ascula access p ocedu es p io o pa icipa ing in he s udy. S anda d moni o ing including
elec oca diog aphy, pulse oxime y, and non-in asi e blood p essu e measu emen was applied o all pa ien s. Pa ien s
we e posi ioned supine wi h a 15-deg ee T endelenbu g il and he head u ned away om he inse ion si e.
Fo he landma k-based g oup, he in acla icula app oach was employed. The inse ion si e was iden i ied a he junc ion
o he middle and medial hi ds o he cla icle, app oxima ely one cen ime e below he in e io bo de . A e s e ile
p epa a ion and d aping, local anes hesia was in il a ed wi h 2% lignocaine. An 18-gauge inde needle was inse ed a a
30-45 deg ee angle o he skin, di ec ed owa d he sup as e nal no ch, wi h cons an gen le aspi a ion un il enous blood
was ob ained. The Seldinge echnique was hen employed o ca he e inse ion using iple-lumen 7 F ench ca he e s.
Fo he ul asound-guided g oup, bo h sup acla icula and in acla icula app oaches we e pe mi ed based on ope a o
p e e ence and ana omical conside a ions. A high- equency linea ul asound p obe (7-13 MHz) was used o essel
iden i ica ion and needle guidance. The subcla ian ein was iden i ied in he sho axis, and i s ela ionship o he
subcla ian a e y was con i med wi h colo Dopple imaging. Fo he sup acla icula app oach, he p obe was placed in
he sup acla icula ossa o isualize he junc ion o he in e nal jugula and subcla ian eins. Fo he in acla icula
app oach, he p obe was placed longi udinally in he in acla icula egion. Real- ime ul asound guidance was used o
isualize needle inse ion and con i m in a enous placemen be o e guidewi e ad ancemen . The Seldinge echnique was
subsequen ly employed o ca he e inse ion.
Ou come Measu es
The p ima y ou come measu es included i s -a emp success a e, de ined as success ul enous cannula ion and guidewi e
placemen on he i s needle inse ion, and o e all success a e, de ined as success ul ca he e placemen ega dless o he
numbe o a emp s. Mechanical complica ions we e me iculously documen ed, including a e ial punc u e con i med by
pulsa ile b igh ed blood e u n, pneumo ho ax con i med by pos -p ocedu e ches adiog aphy, hemo ho ax, hema oma
o ma ion, ca he e malposi ion, and o he complica ions such as ho acic duc inju y o b achial plexus inju y.
Seconda y ou come measu es comp ised p ocedu e ime measu ed om ini ial skin punc u e o success ul guidewi e
placemen in minu es, numbe o needle inse ion a emp s equi ed o success ul ca he e iza ion, pa ien discom o sco es
assessed using a isual analog scale om 0 o 10, and ca he e ip posi ion con i med by ches adiog aphy. Immedia e
pos -p ocedu e ches adiog aphy was pe o med o all pa ien s o con i m ca he e posi ion and ule ou pneumo ho ax.
Follow-up P o ocol
All pa ien s we e ollowed o 48 hou s pos -p ocedu e o un il ca he e emo al i ea lie . Daily assessmen s we e
pe o med o iden i y delayed complica ions including in ec ion, h ombosis, and ca he e dys unc ion. Ca he e - ela ed
bloods eam in ec ions we e de ined acco ding o Cen e s o Disease Con ol and P e en ion c i e ia.
S a is ical Analysis
Da a we e analyzed using SPSS e sion 25.0 so wa e. Ca ego ical a iables we e exp essed as equencies and pe cen ages
and compa ed using chi-squa e es o Fishe 's exac es as app op ia e. Con inuous a iables we e es ed o no mali y
using he Kolmogo o -Smi no es . No mally dis ibu ed con inuous a iables we e exp essed as mean ± s anda d
de ia ion and compa ed using independen samples - es . Non-no mally dis ibu ed a iables we e exp essed as median
Majo D . Bimal Ahluwalia, e al. Ul asound-Guided Ve sus Landma k-Based Subcla ian Vein Ca he e iza ion: A
Te ia y Ca e Cen e Expe ience. In . J Med. Pha m. Res., 6 (6): 504‐513, 2025
508
wi h in e qua ile ange and compa ed using Mann-Whi ney U es . Mul i a ia e logis ic eg ession analysis was pe o med
o iden i y independen p edic o s o p ocedu al success and complica ions. A p- alue o less han 0.05 was conside ed
s a is ically signi ican o all analyses. Rela i e isk wi h 95% con idence in e als was calcula ed o complica ion a es.
RESULTS
Du ing he s udy pe iod om June 2024 o July 2025, a o al o 200 pa ien s equi ing subcla ian cen al enous
ca he e iza ion we e en olled and alloca ed in o wo g oups o 100 pa ien s each. The ul asound-guided g oup comp ised
100 pa ien s who unde wen ca he e iza ion wi h eal- ime ul asound guidance, while he landma k-based g oup included
100 pa ien s who unde wen adi ional landma k-based ca he e iza ion. All en olled pa ien s comple ed he s udy p o ocol
wi h no d opou s o p o ocol iola ions.
The demog aphic and baseline cha ac e is ics o bo h g oups we e compa able wi h no s a is ically signi ican di e ences.
The mean age o pa ien s in he ul asound-guided g oup was 48.6 ± 14.2 yea s compa ed o 49.8 ± 15.1 yea s in he
landma k-based g oup (p=0.549). The gende dis ibu ion showed 58% males and 42% emales in he ul asound-guided
g oup e sus 54% males and 46% emales in he landma k-based g oup (p=0.567). The mean body mass index was simila
be ween g oups a 24.3 ± 3.8 kg/m² in he ul asound-guided g oup and 24.7 ± 4.2 kg/m² in he landma k-based g oup
(p=0.476). The dis ibu ion o clinical indica ions o cen al enous ca he e iza ion was also compa able be ween g oups.
Hemodynamic moni o ing was he indica ion in 42% o ul asound-guided and 38% o landma k-based cases,
adminis a ion o asoac i e d ugs in 28% e sus 32%, hemodialysis in 18% e sus 17%, pa en e al nu i ion in 8% e sus
9%, and long- e m in a enous he apy in 4% e sus 4% o cases espec i ely (p=0.856).
The p ima y ou come o i s -a emp success a e demons a ed a s a is ically signi ican di e ence be ween he wo
echniques. In he ul asound-guided g oup, 87 pa ien s (87%) achie ed success ul cannula ion on he i s needle inse ion
compa ed o 64 pa ien s (64%) in he landma k-based g oup, yielding a p- alue o less han 0.001 using chi-squa e analysis.
This ep esen ed an absolu e isk educ ion o 23% and a ela i e isk o 1.36 (95% con idence in e al 1.18-1.56) a o ing
ul asound guidance. The o e all success a e, de ined as success ul ca he e placemen ega dless o he numbe o
a emp s, was also signi ican ly highe in he ul asound-guided g oup a 98% compa ed o 91% in he landma k-based
g oup (p=0.021). Two pa ien s in he ul asound-guided g oup equi ed con e sion o in e nal jugula ca he e iza ion due
o echnical di icul ies, while nine pa ien s in he landma k-based g oup equi ed al e na i e si e selec ion a e
unsuccess ul subcla ian a emp s.
The mean numbe o needle inse ion a emp s equi ed o success ul ca he e iza ion was signi ican ly lowe in he
ul asound-guided g oup a 1.2 ± 0.5 a emp s compa ed o 1.8 ± 0.9 a emp s in he landma k-based g oup (p<0.001 by
independen samples - es ). In he ul asound-guided g oup, 87% o pa ien s equi ed only one a emp , 11% equi ed wo
a emp s, and 2% equi ed h ee o mo e a emp s. In con as , he landma k-based g oup showed 64% wi h one a emp ,
23% wi h wo a emp s, and 13% equi ing h ee o mo e a emp s. This dis ibu ion was signi ican ly di e en be ween
g oups (p<0.001 by chi-squa e es o end).
The mean p ocedu e ime, measu ed om ini ial skin punc u e o success ul guidewi e placemen , was signi ican ly sho e
in he ul asound-guided g oup a 8.4 ± 2.3 minu es compa ed o 11.2 ± 3.8 minu es in he landma k-based g oup (p<0.001
by independen samples - es ). This di e ence emained s a is ically signi ican e en when analyzing only i s -a emp
success ul cases, wi h mean imes o 7.8 ± 1.9 minu es e sus 9.6 ± 2.8 minu es espec i ely (p<0.001).
The o e all complica ion a e was signi ican ly lowe in he ul asound-guided g oup a 8% compa ed o 23% in he
landma k-based g oup (p=0.003 by chi-squa e es ), co esponding o a ela i e isk o 0.35 (95% con idence in e al 0.17-
0.71). A e ial punc u e, he mos common complica ion, occu ed in 2 pa ien s (2%) in he ul asound-guided g oup
compa ed o 12 pa ien s (12%) in he landma k-based g oup (p=0.006 by Fishe 's exac es ). All cases o a e ial punc u e
we e ecognized immedia ely and managed wi h p olonged comp ession wi hou sequelae. Pneumo ho ax, con i med by
pos -p ocedu e ches adiog aphy, occu ed in 1 pa ien (1%) in he ul asound-guided g oup e sus 6 pa ien s (6%) in he
landma k-based g oup (p=0.048 by Fishe 's exac es ). All pneumo ho aces we e small and equi ed only obse a ion
excep o one case in he landma k-based g oup ha equi ed ches ube d ainage.
Hema oma o ma ion a he inse ion si e occu ed in 3 pa ien s (3%) in he ul asound-guided g oup and 4 pa ien s (4%)
in he landma k-based g oup, which was no s a is ically signi ican (p=0.702). Ca he e malposi ion, de ined as ca he e
ip loca ion ou side he supe io ena ca a con i med by ches adiog aphy, occu ed in 2 pa ien s (2%) in he ul asound-
guided g oup compa ed o 1 pa ien (1%) in he landma k-based g oup (p=0.561), ep esen ing no signi ican di e ence.
No cases o hemo ho ax, ho acic duc inju y, o ne e inju y we e obse ed in ei he g oup du ing he s udy pe iod.
Pa ien - epo ed discom o sco es using a isual analog scale om 0 o 10 showed signi ican ly lowe median sco es in
he ul asound-guided g oup a 3 (in e qua ile ange 2-4) compa ed o 5 (in e qua ile ange 3-6) in he landma k-based
g oup (p<0.001 by Mann-Whi ney U es ). This di e ence was a ibu ed o he ewe needle a emp s and sho e p ocedu e
imes in he ul asound-guided g oup.
Majo D . Bimal Ahluwalia, e al. Ul asound-Guided Ve sus Landma k-Based Subcla ian Vein Ca he e iza ion: A
Te ia y Ca e Cen e Expe ience. In . J Med. Pha m. Res., 6 (6): 504‐513, 2025
509
Subg oup analysis based on ope a o expe ience e ealed ha bo h expe ienced ope a o s ( hose wi h mo e han i e yea s
o expe ience) and less expe ienced ope a o s ( wo o i e yea s o expe ience) achie ed be e ou comes wi h ul asound
guidance compa ed o he landma k echnique. Fo expe ienced ope a o s, i s -a emp success a es we e 92% wi h
ul asound guidance e sus 72% wi h he landma k echnique (p=0.008). Fo less expe ienced ope a o s, he di e ence
was mo e p onounced a 82% e sus 56% espec i ely (p<0.001). This inding sugges ed ha ul asound guidance may be
pa icula ly bene icial o ope a o s wi h less expe ience in subcla ian ca he e iza ion.
Body mass index s a i ica ion demons a ed ha ul asound guidance was associa ed wi h imp o ed ou comes ac oss all
BMI ca ego ies, bu he bene i was mos p onounced in obese pa ien s (BMI g ea e han 30 kg/m²). In his subg oup, i s -
a emp success a es we e 81% wi h ul asound guidance compa ed o only 48% wi h he landma k echnique (p=0.003),
whe eas in pa ien s wi h no mal BMI (18.5-24.9 kg/m²), he a es we e 89% e sus 71% espec i ely (p=0.028).
Analysis o ca he e - ela ed complica ions du ing he 48-hou ollow-up pe iod e ealed no signi ican di e ences be ween
g oups. Ca he e - ela ed bloods eam in ec ion occu ed in 1 pa ien in each g oup (1% e sus 1%, p=1.000). Ca he e
dys unc ion equi ing manipula ion o eplacemen occu ed in 2 pa ien s (2%) in he ul asound-guided g oup and 3
pa ien s (3%) in he landma k-based g oup (p=0.651), ep esen ing no signi ican di e ence.
Mul i a ia e logis ic eg ession analysis iden i ied ul asound guidance as an independen p edic o o i s -a emp success
(odds a io 3.68, 95% con idence in e al 1.92-7.05, p<0.001) a e adjus ing o ope a o expe ience, pa ien BMI, and
indica ion o ca he e iza ion. Simila ly, ul asound guidance was iden i ied as an independen p o ec i e ac o agains
o e all complica ions (odds a io 0.29, 95% con idence in e al 0.12-0.68, p=0.004).
TABLE 1: Demog aphic and Baseline Cha ac e is ics
Cha ac e is ic
Ul asound-Guided G oup (n=100)
Landma k-Based G oup (n=100)
p-
alue
Age (yea s), mean ± SD
48.6 ± 14.2
49.8 ± 15.1
0.549
Male gende , n (%)
58 (58%)
54 (54%)
0.567
BMI (kg/m²), mean ± SD
24.3 ± 3.8
24.7 ± 4.2
0.476
Indica ion, n (%)
0.856
Hemodynamic moni o ing
42 (42%)
38 (38%)
Vasoac i e d ug adminis a ion
28 (28%)
32 (32%)
Hemodialysis
18 (18%)
17 (17%)
Pa en e al nu i ion
8 (8%)
9 (9%)
Long- e m IV he apy
4 (4%)
4 (4%)
Como bidi ies, n (%)
Hype ension
38 (38%)
42 (42%)
0.565
Diabe es melli us
26 (26%)
29 (29%)
0.631
Ch onic kidney disease
22 (22%)
20 (20%)
0.724
Malignancy
14 (14%)
16 (16%)
0.692
Ope a o Expe ience, n (%)
0.891
2-5 yea s
44 (44%)
46 (46%)
>5 yea s
56 (56%)
54 (54%)
SD = S anda d De ia ion; BMI = Body Mass Index; IV = In a enous
TABLE 2: P ima y and Seconda y Ou comes
Ou come
Ul asound-Guided G oup
(n=100)
Landma k-Based G oup
(n=100)
p- alue
Fi s -a emp success, n (%)
87 (87%)
64 (64%)
<0.001*
O e all success, n (%)
98 (98%)
91 (91%)
0.021*
Numbe o a emp s, mean ± SD
1.2 ± 0.5
1.8 ± 0.9
<0.001*
Numbe o a emp s, n (%)
<0.001*
1 a emp
87 (87%)
64 (64%)
2 a emp s
11 (11%)
23 (23%)
≥3 a emp s
2 (2%)
13 (13%)
P ocedu e ime (min), mean ± SD
8.4 ± 2.3
11.2 ± 3.8
<0.001*
P ocedu e ime ( i s -a emp success),
mean ± SD
7.8 ± 1.9
9.6 ± 2.8
<0.001*
Pa ien discom o sco e (0-10), median
(IQR)
3 (2-4)
5 (3-6)
<0.001*
Ca he e ip in op imal posi ion, n (%)
98 (98%)
99 (99%)
0.561
SD = S anda d De ia ion; IQR = In e qua ile Range; * = S a is ically signi ican (p<0.05)
Majo D . Bimal Ahluwalia, e al. Ul asound-Guided Ve sus Landma k-Based Subcla ian Vein Ca he e iza ion: A
Te ia y Ca e Cen e Expe ience. In . J Med. Pha m. Res., 6 (6): 504‐513, 2025
510
TABLE 3: Complica ion Ra es
Complica ion
Ul asound-Guided G oup
(n=100)
Landma k-Based G oup
(n=100)
p-
alue
Rela i e Risk
(95% CI)
O e all complica ions, n
(%)
8 (8%)
23 (23%)
0.003*
0.35 (0.17-0.71)
A e ial punc u e, n (%)
2 (2%)
12 (12%)
0.006*
0.17 (0.04-0.73)
Pneumo ho ax, n (%)
1 (1%)
6 (6%)
0.048*
0.17 (0.02-1.36)
Hema oma, n (%)
3 (3%)
4 (4%)
0.702
0.75 (0.17-3.28)
Ca he e malposi ion, n
(%)
2 (2%)
1 (1%)
0.561
2.00 (0.18-21.74)
Hemo ho ax, n (%)
0 (0%)
0 (0%)
-
-
Ne e inju y, n (%)
0 (0%)
0 (0%)
-
-
48-hou complica ions
Ca he e - ela ed
in ec ion, n (%)
1 (1%)
1 (1%)
1.000
1.00 (0.06-15.77)
Ca he e dys unc ion, n
(%)
2 (2%)
3 (3%)
0.651
0.67 (0.11-3.91)
CI = Con idence In e al; * = S a is ically signi ican (p<0.05)
TABLE 4: Ou comes S a i ied by Ope a o Expe ience
Ou come
Expe ienced Ope a o s (>5
yea s)
Less Expe ienced Ope a o s (2-5
yea s)
Fi s -a emp success, n (%)
Ul asound-guided (n=56/44)
51/56 (91%)
36/44 (82%)
Landma k-based (n=54/46)
39/54 (72%)
26/46 (56%)
p- alue
0.008*
<0.001*
O e all complica ions, n (%)
Ul asound-guided (n=56/44)
3/56 (5%)
5/44 (11%)
Landma k-based (n=54/46)
10/54 (19%)
13/46 (28%)
p- alue
0.022*
0.036*
Mean p ocedu e ime (min), mean ±
SD
Ul asound-guided (n=56/44)
7.8 ± 2.1
9.2 ± 2.4
Landma k-based (n=54/46)
10.2 ± 3.2
12.4 ± 4.1
p- alue
<0.001*
<0.001*
SD = S anda d De ia ion; * = S a is ically signi ican (p<0.05)
TABLE 5: Ou comes S a i ied by Body Mass Index
BMI Ca ego y
No mal (18.5-24.9)
O e weigh (25-29.9)
Obese (≥30)
Pa ien s, n (%)
Ul asound-guided
46 (46%)
37 (37%)
17 (17%)
Landma k-based
43 (43%)
39 (39%)
18 (18%)
Fi s -a emp success, n (%)
Ul asound-guided
41/46 (89%)
32/37 (86%)
14/17 (82%)
Landma k-based
31/43 (72%)
24/39 (62%)
9/18 (50%)
p- alue
0.028*
0.012*
0.035*
Complica ions, n (%)
Ul asound-guided
2/46 (4%)
3/37 (8%)
3/17 (18%)
Landma k-based
7/43 (16%)
9/39 (23%)
7/18 (39%)
p- alue
0.044*
0.064
0.171
Mean p ocedu e ime (min), mean ± SD
Ul asound-guided
7.6 ± 2.0
8.5 ± 2.2
10.2 ± 2.8
Landma k-based
9.8 ± 3.2
11.4 ± 3.6
13.8 ± 4.2
p- alue
<0.001*
<0.001*
0.008*
BMI = Body Mass Index (kg/m²); SD = S anda d De ia ion; * = S a is ically signi ican (p<0.05)
TABLE 6: Mul i a ia e Logis ic Reg ession Analysis o P edic o s o Fi s -A emp Success and Complica ions
Va iable
Fi s -A emp Success
O e all Complica ions
OR (95% CI)
p- alue
Majo D . Bimal Ahluwalia, e al. Ul asound-Guided Ve sus Landma k-Based Subcla ian Vein Ca he e iza ion: A
Te ia y Ca e Cen e Expe ience. In . J Med. Pha m. Res., 6 (6): 504‐513, 2025
511
Ul asound guidance ( s landma k)
3.68 (1.92-7.05)
<0.001*
Ope a o expe ience >5 yea s ( s 2-5 yea s)
2.14 (1.08-4.24)
0.029*
BMI (pe 1 kg/m² inc ease)
0.92 (0.86-0.99)
0.021*
Age (pe 1 yea inc ease)
1.00 (0.98-1.02)
0.892
Male gende ( s emale)
1.24 (0.65-2.36)
0.517
Eme gency indica ion ( s elec i e)
0.71 (0.35-1.44)
0.341
OR = Odds Ra io; CI = Con idence In e al; BMI = Body Mass Index; * = S a is ically signi ican (p<0.05)
DISCUSSION
The p esen compa a i e s udy demons a es signi ican ad an ages o ul asound-guided subcla ian ein ca he e iza ion
o e he adi ional landma k-based echnique in e ms o i s -a emp success a es, o e all success a es, complica ion
a es, and p ocedu e imes. These indings align wi h he g owing body o e idence suppo ing he use o ul asound
guidance o cen al enous access and ex end his e idence speci ically o he subcla ian app oach in a e ia y ca e se ing
wi h di e se pa ien popula ions and a ying le els o ope a o expe ience.
The i s -a emp success a e o 87% achie ed wi h ul asound guidance in he cu en s udy compa es a o ably wi h
p e ious epo s in he li e a u e. F agou e al. epo ed a i s -a emp success a e o 83% wi h ul asound-guided
sup acla icula app oach compa ed o 59% wi h he landma k in acla icula echnique, demons a ing a simila magni ude
o bene i .(11) Simila ly, a me a-analysis by B ass e al. syn hesizing da a om mul iple s udies ound pooled i s -a emp
success a es o 78% o ul asound-guided e sus 61% o landma k-based subcla ian ca he e iza ion, suppo ing he
supe io i y o ul asound guidance.(12) The sligh ly highe success a es obse ed in ou s udy may e lec ad ances in
ul asound echnology, imp o ed aining p o ocols, and he selec i e use o bo h sup acla icula and in acla icula
app oaches based on indi idual pa ien ana omy and ope a o p e e ence.
The o e all success a e o 98% wi h ul asound guidance in he p esen s udy demons a es he high eliabili y o his
echnique when pe o med by adequa ely ained ope a o s. This inding is consis en wi h he s udy by Keenan who
epo ed o e all success a es exceeding 95% wi h ul asound-guided sup acla icula subcla ian ca he e iza ion.(13) The
91% o e all success a e wi h he landma k echnique in ou s udy alls wi hin he ange o 85-93% epo ed in la ge case
se ies, indica ing ha while he landma k app oach emains e ec i e in he majo i y o cases, ul asound guidance p o ides
addi ional ma gin o sa e y and eliabili y.(14)
The signi ican educ ion in complica ion a es obse ed wi h ul asound guidance, pa icula ly a e ial punc u e and
pneumo ho ax, ep esen s one o he mos clinically impo an indings o his s udy. The a e ial punc u e a e o 2% in
he ul asound-guided g oup compa ed o 12% in he landma k-based g oup demons a es a six- old educ ion in his
po en ially se ious complica ion. This inding is consis en wi h epo s om Ka aki sos e al. who documen ed a e ial
punc u e a es o 1.7% wi h ul asound guidance e sus 10.6% wi h he landma k echnique.(15) The abili y o isualize
he ana omical ela ionship be ween he subcla ian ein and a e y in eal- ime and o con i m enous a he han a e ial
cannula ion be o e guidewi e inse ion likely accoun s o his d ama ic educ ion. While mos a e ial punc u es in ou
s udy we e managed conse a i ely wi h comp ession, inad e en a e ial ca he e placemen can lead o se ious
complica ions including limb ischemia, s oke om emboliza ion, and bleeding complica ions, making his isk educ ion
pa icula ly aluable.
The pneumo ho ax a e o 1% wi h ul asound guidance compa ed o 6% wi h he landma k echnique, while bo h ela i ely
low, ep esen s a s a is ically and clinically signi ican di e ence. F agou e al. simila ly epo ed pneumo ho ax a es o
1.5% e sus 5.1% espec i ely, suppo ing ou indings.(11) The isualiza ion o he pleu a du ing ul asound-guided
p ocedu es allows ope a o s o main ain awa eness o needle ajec o y ela i e o he pleu al in e ace, po en ially
explaining his educ ion. Gi en ha pneumo ho ax can necessi a e ches ube inse ion, p olong hospi al s ays, and in a e
cases p og ess o ension pneumo ho ax, his isk educ ion has meaning ul clinical and economic implica ions.
In e es ingly, se e al s udies ha e epo ed con as ing indings ega ding complica ion a es wi h ul asound guidance o
subcla ian ca he e iza ion. Timsi e al. conduc ed a mul icen e andomized ial compa ing ul asound guidance o
landma k echnique o subcla ian ca he e iza ion and ound no signi ican di e ence in complica ion a es be ween
g oups.(16) Howe e , ha s udy has been c i icized o including ope a o s wi h limi ed ul asound expe ience and o no
s anda dizing he ul asound app oach used. Simila ly, a e ospec i e analysis by Sznajde e al. ound compa able
complica ion a es be ween echniques bu no ed ha ul asound guidance was associa ed wi h educed complica ions in
pa ien s wi h di icul ana omy, including hose wi h obesi y o p e ious ca he e iza ions.(17) These disc epan indings
highligh he impo ance o adequa e aining and ope a o expe ience wi h ul asound-guided echniques, as well as pa ien
selec ion ac o s ha may in luence he magni ude o bene i de i ed om ul asound guidance.
The sho e p ocedu e ime obse ed wi h ul asound guidance in ou s udy, a e aging 8.4 minu es compa ed o 11.2
minu es o he landma k echnique, con as s wi h some epo s sugges ing ha ul asound guidance may p olong
p ocedu e ime, pa icula ly du ing he lea ning phase. T oianos e al. epo ed simila p ocedu e imes be ween echniques
once ope a o s had comple ed hei lea ning cu e.(18) The ime sa ed wi h ul asound guidance in ou s udy likely e lec s
Majo D . Bimal Ahluwalia, e al. Ul asound-Guided Ve sus Landma k-Based Subcla ian Vein Ca he e iza ion: A
Te ia y Ca e Cen e Expe ience. In . J Med. Pha m. Res., 6 (6): 504‐513, 2025
512
he highe i s -a emp success a e and ewe needle passes equi ed, o se ing any addi ional ime needed o ul asound
se up and essel iden i ica ion. In clinical p ac ice, his ime sa ings can be meaning ul when mul iple p ocedu es a e
pe o med o in u gen si ua ions whe e apid access is equi ed.
The subg oup analysis based on ope a o expe ience e eals impo an insigh s in o he di e en ial bene i o ul asound
guidance ac oss expe ience le els. While bo h expe ienced and less expe ienced ope a o s achie ed be e ou comes wi h
ul asound guidance, he magni ude o bene i was g ea e o less expe ienced ope a o s. This inding sugges s ha
ul asound guidance may help mi iga e he lea ning cu e associa ed wi h subcla ian ca he e iza ion and imp o e sa e y
du ing he skill acquisi ion phase. Blai as e al. simila ly epo ed ha ul asound guidance was pa icula ly bene icial o
no ice ope a o s a emp ing subcla ian ca he e iza ion.(19) This has impo an implica ions o aining p og ams and
sugges s ha ul asound guidance should be in eg a ed ea ly in p ocedu al aining a he han ese ed o di icul cases
o expe ienced p ac i ione s.
The analysis s a i ied by body mass index demons a es ha ul asound guidance p o ides bene i s ac oss all BMI
ca ego ies bu is pa icula ly aluable in obese pa ien s. The i s -a emp success a e o 81% in obese pa ien s wi h
ul asound guidance compa ed o only 48% wi h he landma k echnique ep esen s a d ama ic di e ence ha likely e lec s
he di icul y o iden i ying ana omical landma ks and main aining app op ia e needle ajec o y in pa ien s wi h inc eased
subcu aneous issue. P abhu e al. simila ly ound ha ul asound guidance was mos bene icial in pa ien s wi h BMI g ea e
han 30 kg/m², suppo ing ou indings.(20) This obse a ion has p ac ical implica ions o pa ien selec ion and sugges s
ha ul asound guidance should be s ongly conside ed o obese pa ien s equi ing subcla ian ca he e iza ion.
The pa ien - epo ed discom o sco es we e signi ican ly lowe in he ul asound-guided g oup, likely e lec ing he ewe
needle a emp s and sho e p ocedu e du a ion. While pa ien com o du ing cen al enous ca he e iza ion is o en
o e looked in a o o mo e objec i e ou come measu es, i ep esen s an impo an quali y indica o and can in luence
pa ien sa is ac ion and coope a ion du ing he p ocedu e. The educed discom o associa ed wi h ul asound guidance
ep esen s an addi ional pa ien -cen e ed bene i beyond he echnical and sa e y ad an ages.
Se e al limi a ions o he p esen s udy wa an conside a ion. The non- andomized design may ha e in oduced selec ion
bias, al hough he consecu i e alloca ion pa e n and compa able baseline cha ac e is ics be ween g oups sugges ha such
bias was minimal. The s udy was conduc ed a a single e ia y ca e cen e , which may limi gene alizabili y o o he se ings
wi h di e en pa ien popula ions, ope a o expe ience le els, o esou ce a ailabili y. All ope a o s in he ul asound-
guided g oup had comple ed s anda dized aining in ul asound-guided ascula access, which may no e lec he
expe ience le el o ope a o s a ins i u ions whe e ul asound guidance is newly implemen ed. The s udy did no include
long- e m ollow-up beyond 48 hou s, so la e complica ions such as ca he e - ela ed h ombosis o ch onic complica ions
could no be assessed. Finally, he s udy did no include a o mal cos -e ec i eness analysis, which would be aluable o
ins i u ions conside ing implemen a ion o ou ine ul asound guidance o subcla ian ca he e iza ion.
Despi e hese limi a ions, he p esen s udy p o ides obus e idence suppo ing he supe io i y o ul asound-guided
subcla ian ein ca he e iza ion in a eal-wo ld e ia y ca e se ing. The consis ency o bene i s ac oss mul iple ou come
measu es and pa ien subg oups s eng hens he alidi y o hese indings. The esul s suppo he adop ion o ul asound
guidance as he p e e ed echnique o subcla ian cen al enous access when ained ope a o s and equipmen a e
a ailable, while acknowledging ha p o iciency in landma k echniques emains impo an o si ua ions whe e ul asound
is una ailable.
Fu u e esea ch di ec ions should include andomized con olled ials in di e se heal hca e se ings, long- e m ollow-up
s udies assessing ca he e - ela ed complica ions and h ombosis a es, cos -e ec i eness analyses compa ing he wo
echniques, s udies e alua ing op imal aining me hodologies o ul asound-guided subcla ian ca he e iza ion, and
in es iga ion o no el ul asound app oaches ha may u he imp o e success a es and sa e y. Addi ionally,
implemen a ion science s udies examining ba ie s and acili a o s o adop ion o ul asound-guided subcla ian
ca he e iza ion in esou ce-limi ed se ings would be aluable o de eloping p ac ical guidelines applicable ac oss di e se
heal hca e sys ems.
CONCLUSION
This compa a i e s udy demons a es ha ul asound-guided subcla ian ein ca he e iza ion o e s signi ican ad an ages
o e he adi ional landma k-based echnique in a e ia y ca e se ing. The ul asound-guided app oach achie ed highe
i s -a emp success a es, imp o ed o e all success a es, educed mechanical complica ions including a e ial punc u e
and pneumo ho ax, and sho e p ocedu e imes. These bene i s we e consis en ac oss ope a o expe ience le els and
pa ien body mass index ca ego ies, wi h pa icula ly p onounced ad an ages obse ed in less expe ienced ope a o s and
obese pa ien s.
The indings suppo he adop ion o ul asound guidance as he p e e ed me hod o subcla ian cen al enous
ca he e iza ion when ained pe sonnel and equipmen a e a ailable. Implemen a ion o ou ine ul asound guidance o
subcla ian ca he e iza ion in e ia y ca e cen e s has he po en ial o imp o e pa ien sa e y, educe mo bidi y associa ed
