Real-time ultrasound-guided subclavian vein cannulation - should it be the preferred method for central venous catheterization in critically ill?

Sep 28, 2026

Letter discussing evidence on real-time ultrasound guidance for subclavian vein cannulation in critically ill patients. It contrasts findings from the 3SITES data and earlier landmark-based approaches with studies reporting higher success and lower complication rates using ultrasound. The letter highlights the SAVES technique (Seeing Artery and VEin Simultaneously in the long axis) and stresses that ultrasound does not eliminate serious complications. It concludes that the choice of method depends on indication, patient factors, vessel features, operator proficiency, and available resources.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages2

Reading Time5 min

AccessFree to download

Matters Arising

Comparison of ultrasound-guided vs landmark-based approaches

Evidence from trials and SAVES method

Long-axis vs short-axis considerations

Clinical decision factors

Zhang and Zhang Critical Care (2025) 29:541 [https://doi.org/10.1186/s13054-025-05824-7](https://doi.org/10.1186/s13054-025-05824-7) Critical Care MATTERS ARISING Open Access Real-time ultrasound-guided subclavian vein cannulation: should it be the preferred method for central venous catheterization in critically ill? Xinyue Zhang1,2 and Ruyuan Zhang3* We read with great interest the post hoc target trial emulation by Boulet, et al. [1], which utilized 3SITES data to compare the incidence of catheter-related infectious, thrombotic, and mechanical complications among internal jugular, femoral, and subclavian sites, assuming universal real-time ultrasound guidance. They showed that in a total of 989 catheters in the subclavian site, only 50 (5.1%) catheterizations were real-time ultrasound-guided. This means that in their original 3SITES trial [2], most of subclavian vein catheterizations were landmark-based, which was associated with a higher risk of immediate mechanical complications. In contrast, real-time ultrasound can overcome the drawbacks of the landmarkbased subclavian vein access technique and improve its risk-benefit profile. As their current target trial emulation suggests, the incidence of major mechanical complications was markedly lower than that observed in the original trial. In an early study from Fragou et al. [3], real-time ultrasound-guided subclavian catheterization (n = 200) achieved a 100% success rate and decreased artery puncture rate to 0.5%, with no pneumothorax and hemothorax, in contrast with landmark-based method (n = 201) of 87.5% success rate and three complications rate of about 5%, respectively. Another recent randomized controlled trial (n = 449) demonstrated a 99. 1% success rate with a This comment refers to the article available online at [https://doi.org/](https://doi.org/)[ ](https://doi.org/)[10.1186/s13054-025-05747-3](10.1186/s13054-025-05747-3.)[.](10.1186/s13054-025-05747-3.) *Correspondence: Ruyuan Zhang [ruyuan.zhang@hotmail.com](ruyuan.zhang@hotmail.com) 1.1% rate of artery puncture and no cases of pneumothorax [4]. Furthermore, leveraging local anatomical landmarks may improve the safety and efficacy of subclavian vein puncture. To address the limitation of the conventional long axis in-plane technique—which typically visualizes only a single vessel and places the pleura in view beneath the vein — we recently proposed the SAVES method (Seeing Artery and VEin Simultaneously in the long axis) for ultrasound-guided infraclavicular axillary/subclavian vein cannulation. Using SAVES, we achieved a 100% success rate (n = 142) without any cases of pneumothorax, hemothorax, or arterial puncture [5]. However, we acknowledge that this small, non-controlled retrospective study requires confirmation by a larger, controlled prospective study. As the number of punctures increases, the SAVES technique might be impossible to achieve a 100% success rate and without major mechanical complications. We agree with others that we should dismiss the misconception that “serious complications no longer arise when ultrasound is used” [6]. In their present article, it is unknown whether the long-axis or short-axis approach is used. While the longaxis view provides better visualization of the needle tip compared to the short-axis view, it has a longer learning 1Department of Ultrasound, The Affiliated People’s Hospital of Jiangsu University, Zhenjiang, China 2School of Medicine, Jiangsu University, Zhenjiang, China 3Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China © The Author(s) 2026. Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide

FAQs

How often were subclavian cannulations real-time ultrasound-guided in the 3SITES-related analysis?

In the subclavian site, only 50 of 989 catheterizations (5.1%) were real-time ultrasound-guided.

What earlier findings are cited for ultrasound-guided subclavian catheterization versus landmark-based methods?

An early study reported 100% success with ultrasound guidance and a reduced artery puncture rate (0.5%) with no pneumothorax or hemothorax, compared with lower success and more complications for landmark-based access.

Does the letter claim that ultrasound eliminates serious complications?

No. It argues against the misconception that serious complications no longer arise when ultrasound is used and notes that larger controlled prospective confirmation is needed.

Sep 28, 2026

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