Central venous long-term access: Are there new standards?

Despite their wide use, there's no consensus regarding the most efficient or safest method to insert long-term central lines. Basically, insertion can be accomplished by surgical cutdown approach or percutaneously and subclavian percutaneous venipuncture is historically the most popular route. Percutaneous approach to the internal jugular vein is generally considered less prone to severe complications, but data coming from large studies are mostly retrospective. Influence of surgical cutdown on late complications (e.g. venous thrombosis) is so far unknown. At least 14 trials addressed the issue of ultrasound guidance, and in 2002 the NICE (National Institute for Clinical Excellence - UK) produced the recommendation that 2-D imaging ultrasound guidance should be the preferred method when inserting of central venous catheter into the internal jugular vein in 'elective situations'. Aim of this paper is to critically review the available evidence about this topic, demonstrating that further randomised clinical trials of adequate statistic power are still needed to obtain an evidence-based consensus, possibly including differential costs, patients' compliance and satisfaction.