|Year : 2020 | Volume
| Issue : 1 | Page : 46-51
Comparative study between open and ultrasound-guided central venous access devices
Sayed A Elhady1, Elsayed M Abd El-Hamid2
1 Department of Pediatric Surgery, Al-Azhar University, New Damietta, Egypt
2 Department of Diagnostic Radiology, Al-Azhar University, New Damietta, Egypt
|Date of Submission||31-May-2019|
|Date of Decision||26-Oct-2019|
|Date of Acceptance||18-Dec-2019|
|Date of Web Publication||26-Mar-2020|
Elsayed M Abd El-Hamid
Tanah Village, Mansoura, Daqahleya
Source of Support: None, Conflict of Interest: None
Background and aims Pediatric populations represented a challenge for insertion of central venous access devices (CVADs). Ultrasound guidance seems to provide advantages over the open surgical method. However, there are no enough data to advocate this notion. An additional goal was to compare between ultrasound-guided and open surgical venous cut down for central venous catheter (CVC) placement.
Patients and methods The study included 40 patients, divided into two equal groups: group A (open CVAD group) and group B (ultrasound-guided CVAD group). For each group, patient data, procedure success rate, time of the procedure, and any complications were documented and compared in both groups.
Results Both groups were comparable regarding patient age, sex, cauterized vein, indication for CVC insertion, success rate, first-attempt success, number of attempts, and complications.
Conclusion Ultrasound guidance was confirmed to be effective and safe as an open method for insertion of CVC insertion with preservation of the vein intact.
Keywords: central venous catheter, open surgery, pediatrics, ultrasound
|How to cite this article:|
Elhady SA, Abd El-Hamid EM. Comparative study between open and ultrasound-guided central venous access devices. Al-Azhar Assiut Med J 2020;18:46-51
|How to cite this URL:|
Elhady SA, Abd El-Hamid EM. Comparative study between open and ultrasound-guided central venous access devices. Al-Azhar Assiut Med J [serial online] 2020 [cited 2020 Jun 2];18:46-51. Available from: http://www.azmj.eg.net/text.asp?2020/18/1/46/281356
| Introduction|| |
Central venous access devices (CVADs) offer an access to the greater vasculature, thus permitting the administration of drugs contraindicated to be given peripherally. In addition, CVADs are used for longer term therapy and for venous monitoring and withdrawing of blood samples .
Patients in need for CVADs are diverse, of various ages, having acute or chronic illnesses. There are many types of CVADs inserted for different treatment purposes, for example, short-term or long-term duration of therapy, and intermittent or continuous therapy. CVAD care is compound and multi-faceted; clinicians from different clinical specialties are involved in their insertion and management ,,.
The most common veins for insertion of central venous catheter (CVC) are internal jugular, subclavian, and femoral veins .
The selection of the route depends on the clinical situation, indication, and patient characteristics. The traditional placement of CVC by open surgical method was an effective route for both children and adults. The percutaneous insertion was shown to be effective in adults, but in children, it was associated with hemothorax, pneumothorax, accidental arterial puncture, and even death. Thus, the open route is preferred in children ,.
The target vein could be punctured directly or by using ultrasound. However, the technique has some degree of threats for failure and complications .
Two different methods of ultrasound were used: the static method, where targeted vein is visualized on the monitor of ultrasound and a landmark puncture was done and the actual catheterization was completed blindly. On the contrary, in the dynamic ultrasound, the visualization of target vein is a continuous process through whole procedure of catheterization. Ultrasound-guided central vein catheter placement was advocated by many internal health agencies ,. However, its use in such situation remains low .
| Aim|| |
The present study was designed to compare between ultrasound-guided and open surgical method for CVC placement.
| Patients and methods|| |
This prospective comparative study was carried out on 40 patients with mean age of ∼5 years at Al-Azhar University Hospital (New Damietta) (Pediatric Surgery and Radiology Departments) during the period from January 2016 to December 2017.
The study protocol was approved by the local ethics and research committee of Al-Azhar University Hospital (New Damietta), and an informed consent was obtained from each patient guardian for participation in the study.
Patient was excluded if he/she had one or more of the following conditions: (a) subcutaneous emphysema, (b) radiation therapy, (c) skin infection at insertion site, (d) fractured clavicle, (e) urgent patients, and (f) raised intracranial pressure.
Patients were divided into two equal groups:
- Group A (open group).
- Group B (ultrasound-guided group).
The internal jugular and subclavian veins were used for catheter placement in both groups. The placement of the CVC was done under complete aseptic technique. The outcome was measured by documentation of success rate, time to return of venous blood, and any complications.
For each catheter placement, three attempts were allowed as a maximum before announcement of failure of the procedure. The failure was declared if there was no venous blood return from target vein after withdrawal of the needle. Time to return of venous blood was measured from skin puncture to return of venous blood. Chest radiograph was done following 6 h after the procedure to check the position of the catheter and search for pneumothorax. Other perioperative complications were documented.
For the catheterization of internal jugular and subclavian veins, the patient was placed supine with 15° Trendelenburg with a small roll under the patient’s shoulders to extend the neck. The whole skin at the side of the neck and supraclavicular area were sterilized by betadine and covered by a sterile drape. The technique started by 10-mm incision over the chosen vessel, dissection, and direct control of the vein with vessel loops. A venotomy was done, and the central access catheter was passed directly under vision. The venotomy is then closed with a 6-0 or 7-0 Prolene suture ([Figure 1]).
|Figure 1 Open CVAD technique. (a) Transverse incision between two heads of sternomastoid muscle. (b) Control of the vein with vessel loops. (c) CVC inserted under vision. CVAD, central venous access device; CVC, central venous catheter.|
Click here to view
Preprocedure ultrasound examination was done to determine the position of the vein, its caliber, and patency, as proposed by Fragou et al. . For jugular vein catheter insertion, the probe was applied on the lateral aspect of the neck, whereas in the subclavian, the probe was placed on the anterolateral aspect of the thorax 1 cm below the clavicle . Patient preparation and positioning was the same as for patients in the open group. The machine used was the ultrasound machine Toshiba (Toshiba Xario 200, Toshiba Medical System, Japan), using superficial linear transducer of 7.5 MHz. Complete sterilization was accomplished by sterile gel and sterile cover for the probe. The probe was applied in a perpendicular angle to the long axis of the targeted vein, and the needle for catheter was inserted at the middle of the long axis of the probe to accomplish a short-axis out-of-plane approach . The targeted vein was centered into the middle of the screen with slight movement of the probe, and the needle was carefully introduced under ultrasound guidance until the anterior wall is punctured and venous blood was aspirated in the syringe connected to it. After documenting return of the venous blood, the Seldinger’s technique for catheterization was used ([Figure 2]).
|Figure 2 US-guided CVAD technique. (a) US demonstration of internal jugular vein and common carotid artery. (b) Insertion of CVC guided by US. (c) Venous blood aspirated after puncturing the vein. (d) Chest radiogaph PA view for confirmation to the site of CVC. CVAD, central venous access device; CVC, central venous catheter; PA, posterioanterior; US, ultrasound.|
Click here to view
Maintenance procedures were always done according to Fratino et al. . By a heparinized solution, Hickman–Broviac catheters were flushed three times a week. The catheter dressing was changed once a week, starting 7 days after insertion, unless there were signs of infection or hematoma at the exit site. Maintenance procedures were performed by trained pediatric nurses.
The collected data were analyzed by statistical package for social science (SPSS), version 21 (IBM SPSS Inc., Chicago, Illinois, USA). Numerical variables were expressed as mean and SD, whereas qualitative data were expressed as relative frequency (number) and percent distribution. Independent samples Student t test and c2 tests were used for comparison between groups. P value less than 0.05 was considered significant.
| Results|| |
The present study included 40 children, and their age ranged from birthday to 10 years, with a mean age of ∼5 years. Males represented 62.5% of the studied children. There was no significant difference between both groups regarding age, sex, the catheterized vein, and indications of the procedure. The procedure done on the right side in 55% and in internal jugular vein in 95%. The indications were trauma in 35%, operation in 30.0%, nephrological in 22.5%, and hematological in 12.5%.On the contrary, there was a significant increase or right-side catheterization in open when compared with ultrasound-guided (75 vs. 35.0%, respectively) ([Table 1]).
|Table 1 Comparison between groups A and B regarding patient characteristics|
Click here to view
Regarding outcome, the success rate was high in group A when compared with group B (100.0 vs. 95.0%, respectively). However, the difference was statistically nonsignificant. Moreover, there was no statistically significant difference between both groups regarding the number of attempts or complications. In addition, there was no significant difference between groups A and B regarding the first-attempt success (90.0 vs. 75.0%, respectively). The reported complications were arterial puncture in one case in group B and difficult advance of the catheter to functional position in two cases in group A and four cases in group B. Hematoma was reported in three (15%) patients in group A compared with four (20.0%) patients in group B. Bleeding was reported in only one patient in group A, and there was no infection or catheter occlusion (thrombosis) in either groups. Finally, the overall complications were 15 and 20% in groups A and B, respectively, with no significant difference as seen in [Table 2].
| Discussion|| |
Central venous catheterization is a common procedure as it is usually indicated for medications and fluid administration, dialysis, pacing, and monitoring of hemodynamics . The advent of ultrasound guidance is thought to provide many advantages over the traditional methods, as it permits direct visualization of targeted vein and inserted catheter. It is usually associated with higher success rate and less complications ,,. However, there were no enough studies comparing prospectively between the open method and ultrasound-guided central venous catheterization. Hence, the present study comes out to fill in a piece of such gap.
Results of the present work showed that there was no significant difference between open and ultrasound-guided techniques regarding success rate (100.0 vs. 95.0%, respectively) or overall complications rate (15 vs. 20.0%, respectively). These results are comparable to those reported by Vierboom et al.  who reported that their results demonstrated no significant difference between open and ultrasound-guided CVC insertion in infants regarding intraoperative and postoperative complications and overall success rate. However, they reported that there is a significant increase of catheter blockage in open group.
The overall rate of complications in both groups is higher than that reported in literature. For example, Blum et al.  reported a complication rate of 2% for open and 2.6% for ultrasound-guided catheter insertions. The main complications in ultrasound-guided group were bleeding (0.3%) and pneumothorax (1.8%). Avanzini et al.  reported that complications associated with the ultrasound guidance include hemothorax and arterial puncture, and the overall rate of complications with this approach was 2.6%. In addition, Arul et al.  included 500 ultrasound-guided catheters reported a perioperative complication rate of 2.4%. The same authors  published a small series of 36 ultrasound-guided catheter insertions for neonates less than 5 kg of weight and reported no intraoperative complications. The small number of included subjects in the present work could overestimate the complications rate and could be responsible for this contradiction. In addition, the high complication rate in the present work could be attributed to the simple mechanical complications of insertion (such as difficulty in catheter advance to optimal position).
Alshafei et al.  reported that the open cut-down technique was the technique of choice in their center as they lack the interventional radiology devices. They reported that, bleeding owing to vessel injury is the main potential complication intraoperatively, and this has not resulted in any major morbidity or mortality in the past decade, reflecting the safety of the open cut-down technique as reported in the present work.
In the present work, there was no infection or catheter occlusion in either open or ultrasound groups. However, Hosseinpour et al.  reported a patency rate of 91% in open method, and in the largest study from Canada, the rate was 0.35 for 1000 admission . However, venous occlusion rates can range from 0 to 15% and 25 to 33% in the ultrasound-guided and open techniques, respectively ,,. This is owing to the fact that, open cut-downs likely lead to more destruction to the vein .
On the contrary, Lorenz et al.  reported that CVCs in pediatric populations are associated with frequent complications, which could lead to premature removal of catheter. The radiologically guided catheters are associated with lower rates of infectious and mechanical complications compared with surgically placed CVCs. Verghese et al.  added that high success rates at the time of CVC insertion have been shown by the radiologic technique (not the situation in the present work). They also stated that, ultrasound guidance may provide a special gain over surgical technique for small children (as the anatomic landmarks for vein puncture are less distinct). However, they considered all other ways than ultrasound, and thus, it could explain the advantage of ultrasound when they included landmark techniques besides open surgical technique in their comparison.Finally, it is expected that, with improving operator experience, the complications reported with ultrasound-guided group will decrease giving the superiority to ultrasound and permitted its generalizability in CVC insertion. Auyong and Hsiung  reported that ultrasound by itself is not responsible for high safety. It is an instrument that needs exercise and training to recognize its restrictions. Misidentification of anatomic structures, absence of understanding of applied physics related to ultrasound, and insufficient psychomotor abilities to correctly monitor the needle to the desired position while evading nondesired locations can lead to complications even with ultrasound.
| Conclusion|| |
Our study concluded the following: ultrasound guidance was confirmed as effective as open method for insertion of CVC.
Ultrasound-guided central venous insertion is a safe method, with less complication as compared with open method.
So, ultrasound-guided central venous insertion is better than open method.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Loveday HP, Wilson J, Pratt RJ, Golsorkhi M, Tingle A, Bak et al.
Epic3: national evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. J Hosp Infect 2014; 86:S1–S70.
Taylor JE, McDonald SJ, Tan K. Prevention of central venous catheter-related infection in the neonatal unit: a literature review. J Matern Fetal Neonatal Med 2015; 28:1224–1230.
Davis MH. Pediatric central venous catheter management: a review of current practice. JAVA 2013; 18:93–98.
McMullan C, Propper G, Schuhmacher C, Sokoloff L, Harris D, Murphy P, Greene WH. A multidisciplinary approach to reduce central line-associated bloodstream infections. Jt Comm J Qual Patient Saf 2013; 39:61–69.
Bannon MP, Heller F, Rivera M. Anatomic considerations for central venous cannulation. Risk Manag Healthc Policy 2011; 4:27–39.
Nixon SJ. Death after inserting Hickman line was probably avoidable. BMJ 2002; 324:739.
Arul GS, Livingstone H, Bromley P, Bennett J. Ultrasound-guided percutaneous insertion of 2.7 Fr tunnelled Broviac lines in neonates and small infants. Pediatr Surg Int 2010; 26:815–818.
Sazdov D, Srceva MJ, Todorova ZN. Comparative analysis of ultrasound guided central venous catheterization compared to blind catheterization. Pril (Makedon Akad Nauk Umet Odd Med Nauki) 2017; 38:107–114.
Troianos CA, Hartman GS, Glas KE, Skubas NJ, Eberhardt RT, Walker JD, Reeves ST. Guidelines for performing ultrasound guided vascular cannulation: recommendations of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. JASE. 2011; 24:1291–1318.
Maizel J, Bastide MA, Richecoeur J, Frenoy E, Lemaire C, Sauneuf B et al.
Practice of ultrasound-guided central venous catheter technique by the French intensivists: a survey from the BoReal study group. Ann Intensive Care 2016; 6:76–78.
Fragou M, Gravvanis A, Dimitriou V, Papalois A, Kouraklis G, Karabinis A et al.
Real- time ultrasound-guided subclavian vein cannulation versus the landmark method in critical care patients: a prospective randomized study. Crit Care Med 2011; 39:1607–1612.
Fratino G, Molinari AC, Parodi S, Longo S, Saracco P, Castagnola E, Haupt R. Central venous catheter-related complications in children with oncological/haematological disease: an observational study of 418 devices. Ann Oncol 2005; 16:648–654.
Prabhu V, Juneja D, Gopal PB, Sathyanarayanan M, Subhramanyam S, Gandhe S, Shivanand KN. Ultrasound-guided femoral dialysis access placement: a single-center randomized trial. Clin J Am Soc Nephrol 2010; 5:235–239.
Karakitsos D, Nikolaos L, De Groot E, Patrianakos AP, Kouraklis G, Poularas J et al.
Real-time ultrasound-guided catheterisation of the internal jugular vein: a prospective comparison with the landmark technique in critical care patients. Crit Care 2006; 10:162–175.
Vierboom R, Darani A, Langusch C, Soundappan SVS, Karpelowsky J. Tunnelled central venous access devices in small children: a comparison of open vs. ultrasound-guided percutaneous insertion in children weighing ten kilograms or less. Journal of Pediatric Surgery 2018; 53:1832–1838.
Blum LV, Abdel-Rahman U, Klingebiel T, Fiegel H, Gfroerer S, Rolle U. Tunneled central venous catheters in children with malignant and chronic diseases: a comparison of open vs. percutaneous implantation. J Pediatr Surg 2017; 30:30.
Avanzini S, Guida E, Conte M, Faranda F, Buffa P, Granata C et al.
Shifting from open surgical cut down to ultrasound-guided percutaneous central venous catheterization in children: learning curve and related complications. Pediatr Surg Int 2010; 26:819–824.
Arul GS, Lewis N, Bromley P, Bennett J. Ultrasound-guided percutaneous insertion of Hickman lines in children. Prospective study of 500 consecutive procedures. J Pediatr Surg 2009; 44:1371–1376.
Alshafei A, Tareen F, Maphango N, White D, O’Connor B, Sriparan T. Open tunneled central line insertion in children − external or internal jugular vein? J Pediatr Surg. 2018; 53:2318–2321.
Hosseinpour M, Mashadi MR, Behdad S, Azarbad Z.Central venous catheterization in neonates: comparison of complications with percutaneous and open surgical methods. J Indian Assoc Pediatr Surg 2011; 16:99–101.
] [Full text]
Massicotte MP, Dix D, Monagle P, Adams M, Andrew M. Central venous catheter related thrombosis in children: analysis of the Canadian registry of venous thromboembolism complications. J Pediatr 1998; 133:770–776.
Wragg RC, Blundell S, Bader M, Sharif B, Bennett J, Jester I et al.
Patency of neck veins following ultrasound-guided percutaneous Hickman line insertion. Pediatr Surg Int 2014; 30:301–304.
Willetts IE, Ayodeji M, Ramsden WH, Squire R. Venous patency after open central-venous cannulation. Pediatr Surg Int 2000; 16:411–413.
Lorenz JM, Funaki B, Van Ha T, Leef JA. Radiologic placement of implantable chest ports in pediatric patients. AJR 2001; 176:991–994.
Verghese ST, McGill WA, Patel RI, Sell JE, Midgley FM, Ruttimann UE. Ultrasound-guided internal jugular venous cannulation in infants: a prospective comparison with the traditional palpation method. Anesthesiology 1999; 91:71–77.
Auyong DB, Hsiung RL. Ultrasound in central venous cannulation. Adv Anesth 2010; 28:59–79.
[Figure 1], [Figure 2]
[Table 1], [Table 2]