Authors: Conrad D et al.
Anesthesia & Analgesia, 142(5):857–865, May 2026
This randomized controlled trial evaluates whether a fully ultrasound-guided microconvex in-plane subclavian puncture (MISP) technique improves outcomes compared with a traditional landmark approach preceded by ultrasound prescan. Subclavian central venous catheterization remains a common procedure but carries risks such as arterial puncture and pneumothorax, and the optimal use of ultrasound continues to evolve.
A total of 101 patients undergoing elective surgery were randomized to either real-time ultrasound-guided in-plane cannulation (MISP) or a control group using landmark technique after ultrasound prescan. The primary endpoint was a composite risk score incorporating multiple clinically relevant factors, including number of attempts, procedural time, posterior wall injury, arterial puncture, hematoma, pneumothorax, hemothorax, and catheter misplacement. Secondary outcomes included success rates and individual complication rates.
The results demonstrated that the MISP technique significantly reduced the overall composite risk score compared with the landmark-based approach. In addition, overall success rates were higher in the ultrasound-guided group (86% vs 71%), and arterial punctures were significantly reduced (1.9% vs 12%). These findings indicate improved procedural safety and effectiveness with real-time ultrasound guidance. Importantly, there was no difference in pneumothorax rates, with one case observed in each group.
The primary tradeoff identified was an increase in procedural time, with the ultrasound-guided approach taking approximately five minutes longer on average. However, the reduction in complications—particularly arterial puncture—suggests that this additional time is clinically justified.
The authors conclude that real-time ultrasound-guided in-plane subclavian vein puncture using a microconvex probe provides superior safety and higher success rates compared with a landmark technique, even when the latter is preceded by ultrasound prescan. These findings support the broader adoption of dynamic ultrasound guidance as the preferred method for subclavian central venous access.
What You Should Know
Real-time ultrasound-guided in-plane subclavian vein cannulation significantly improves success rates and reduces complications—especially arterial puncture—compared with a landmark-based approach, even when ultrasound is used beforehand for mapping. The slightly longer procedure time is a reasonable tradeoff for improved safety.
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