Ultrasound imaging in vascular access

Tim Maecken, MD; Thomas Grau, MD, PhD

I n experienced hands, the land-mark-based techniques have usu-ally provided inexpensive and effi-cient central venous access (1–5).

Historically, performing blind punctureprocedures depended greatly on a correctknowledge of vascular anatomy and clin-ical experience. Until recently, however,there has been limited detailed informa-tion about the clinical nature of vascularpuncture processing. Basic anatomic find-ings effectively underlie situations such asanomalies in anatomy of vascular struc-tures, dependency on the patient’s move-ments, and an increased variability of vesselposition related to adhesive structures ofthe perivascular area. The landmarkmethod fails, irrespective of anatomy, if thevein has thrombosed and may lead the op-erator to pass the needle in an inappropri-ate direction. All can result in a difficultpuncture with or without complications.Thus, as early as in 1984, authors haverecommended utilizing ultrasound guid-ance to optimize the success rate of cannu-lations and to minimize complications (6).

Vascular Access and PunctureProcedure

The following veins are frequentlyused for a central venous catheter: theinternal jugular, femoral or subclavianvein, and to a lesser extent, the axillaryvein. Using ultrasound for peripheral veinpuncture has been described for para-medics and staff in the emergency depart-ment (7). The basilic or cephalic vein canalso be used for peripherally placed cen-tral venous catheters. The femoral, axil-lary, or radial arteries are common accesssites for the arterial system.

There are a number of different punc-ture techniques for vascular access. Cur-rently, most physicians use only ana-tomic landmarks to guide vascularaccess. With this method, optimized po-sitioning of the patient and accuratemarking of standard anatomic landmarksare required to guide the puncture pro-cedure. Compared with the landmarktechnique, the use of an acoustic Dopplerprovides for more accurate guidance ofthe puncture procedure. Detected signalswith an acoustic Doppler reflect arterialor venous signals by a single A-scan line.Within this line, there is usually either ahigh-frequency signal of an artery or alow-frequency signal for a vein when thevessel is directly under the A-scanningprobe.

The ultrasound procedure of choice isthe two-dimensional ultrasound scan, orso-called B-scan; a B-scan is a depiction

of several A-lines transformed into a sig-nal that is almost identical to an ana-tomic depiction of the subcutaneousstructures. Currently, there is an increas-ing trend toward minimal invasive endo-vascular procedures (e.g., vascular sur-gery, coronary angioplasty). Parallel tothis trend, however, is an increasing rateof iatrogenic pseudoaneurysms, fistulas,or hematomas, which may greatly altersubsequent vascular access options. B-scan imaging can be performed to detectthese lesions (8). With color-Doppler im-aging, irregular blood flow or differencesin flow velocity can be measured. Thiscan be helpful in determining the accesssite and in optimizing the exact localiza-tion of catheter placement.

The needle can be guided through thetissue directly or indirectly. In indirectultrasound guidance, ultrasound scansare performed before puncture and nee-dle insertion is without ultrasound. Wethink that this technique is not the bestchoice for vessel cannulation when veryprecise needle placement is required butthat this may be suitable in other situa-tions, such as in the drainage of pleuraleffusions.

Direct ultrasound guidance visualizesthe needle in real time, throughout thepuncture process. A technical option is touse accessory needle guidance devicesthat fit exactly on the probe to control theneedle trajectory. However, we prefer thedirect free-hand puncture technique formore flexibility. With this technique, one

From BG University Hospital Bergmannsheil, Clinicof Anaesthesiology, Intensive Care, Palliative Care andPain Therapy Ruhr-University Bochum Buerkle-de-la-Camp-Platz 1, Bochum, Germany.

The authors have not disclosed any potential con-flicts of interest.

For information regarding this article, E-mail:maecken@anaesthesia.de.

Copyright © 2007 by the Society of Critical CareMedicine and Lippincott Williams & Wilkins

DOI: 10.1097/01.CCM.0000260629.86351.A5

Physicians spend a considerable amount of time and effortinserting catheters and needles into patients. Central venouscatheters are the mainstay of measuring hemodynamic variablesthat cannot be assessed by noninvasive procedures. These cath-eters also allow hemodialysis, parenteral nutritional support, de-livery of medications, and catecholamine administration. Arterialpressure catheters are frequently used for hemodynamic monitoringand for obtaining arterial blood gases in critically ill patients. Suchuse of arterial and central venous catheters, however, is potentiallyassociated with severe complications that can be injurious to pa-tients and expensive to treat. Techniques involving the use of ana-

tomic landmarks have been the traditional mainstay of accessing thecentral venous system for decades. With the development and re-finement of portable and affordable high-resolution ultrasound de-vices, imaging vascular access has changed the role of the tradi-tional landmark techniques. In this article, we explain the use ofultrasound for vascular access to reduce complications associatedwith cannulation of veins and arteries. We will also provide a briefoverview of the current literature regarding ultrasound-guided vas-cular access. (Crit Care Med 2007; 35[Suppl.]:S178–S185)

KEY WORDS: medical subject headings; ultrasound; catheteriza-tion; complications; arterial vessel access

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hand holds the ultrasound probe and theother the needle. Unfortunately, thistechnique requires high operator skillsand experience.

The authors perform vascular accessusing a single-operator technique. Al-though the ultrasound probe has to bedisengaged to introduce the guidewire,no problems were experienced withoutcontinuous visualization of the process ofinserting the wire. In our opinion, a two-operator technique could be useful whenproblems occur while introducing theguidewire. However, the authors were al-ready experienced in central venous ac-cess when starting to use ultrasound forvascular access. We do confirm the in-travascular position of the wire afterinsertion. A study focusing on the spe-cific question of whether single- vs.two-operator technique was advanta-geous revealed no significant differ-ences. Unfortunately, only 44 patientswere studied (9).

Ultrasound gel is required for acousticcoupling between ultrasound probe, pro-tective sheath, and the skin surface. Thegel must be sterile for interventional us-age, both inside and outside the long,sterile plastic sheath. Local anestheticand sterile saline solutions might alsoserve as coupling substances, especiallyin a patient who is awake.

Scans of the vessels can be longitudi-nal or cross-sectional. Similarly, needleinsertion can be performed in either lon-gitudinal or transverse relation to the ul-trasound probe. The choice of axis de-pends on the location of the vessel,operator experience, and anatomic rela-tionships. For the very common cannu-lation of the internal jugular vein (IJV),

we typically use a cross-sectional scan fora better view of the surrounding struc-tures. However, puncturing a vessel incross-sectional imaging with transverseneedle placement can be difficult; a hy-perechogenic signal (white spot) is seenwhen the needle is in axis to the ultra-sound beam (Fig. 1). Ideally, this whitespot is the tip of the needle and not theshaft. In this situation, the operator doesnot always know where the end of theneedle actually is placed. Despite thesedifficulties, Blaivas et al. (10) reportedthat the technique utilizing a transverse,short-axis view of the needle in vascularaccess was easier for novices to learn thana technique using longitudinal scan.

Mechanical Complications ofCentral Venous Catheterizationin Adults

Safe cannulation of the IJV was de-scribed by Hermosura et al. (5) in adultsin 1966 using the landmark technique.Nevertheless, there are reports of up to a40% complication rate (Table 1). Com-mon complications for central venous ac-cess include accidental arterial puncture,hematoma, pneumothorax (11, 12), andeven death (13). Serious bleeding-relatedconsequences of accidental arterial punc-ture include hematoma of the neck andhematoma of the mediastinum or hemo-thorax. There are also possibilities of po-tential damage to the cervicothoracicganglion (stellate ganglion), phrenicnerves, and other important nerves de-scribed (14–16). McGee and Gould (17)described complications of central ve-nous catheters to be dependent on the

route of cannulation. They found a rate ofaccidental arterial puncture during ac-cess of the IJV of 6.3–9.4%. Hematomaoccurred in 0.1–2.2%. The relatively rarecomplication of a pneumothorax whileaccessing the IJV happened in 0.1–0.2%of cases. In contrast to IJV catheteriza-tion, cannulation of the subclavian veinwas associated with a higher rate ofpneumothorax or hemothorax (1.5–3.1%and 0.4–0.6%, respectively). Accidentalpuncture of the subclavian artery oc-curred in 3.1–4.9% of cases. Comparedwith cannulation of the internal jugularand subclavian veins, the highest rate ofarterial puncture and hematoma oc-curred while accessing the femoral vein(9.0–15% and 3.8–4.4%, respectively). Arecently published study by Eisen et al.(18) reported mechanical complicationsin 14% (excluding failed attempts) forcentral venous cannulation in 385 criti-cally ill patients. Only 67% (256 of 385patients) had an uneventful catheter in-sertion. This publication confirms thefrequency of accidental arterial punctureby catheter insertion site reported byMcGee and Gould (17): highest rate forfemoral approach (7.1%), followed byjugular approach (5.0%), and lowest forsubclavian approach (3.2%). Other com-plications (pneumothorax, hematoma,incorrect position) were also comparablewith previous publications (12, 19–21).Eisen et al. (18) defined “failure to place”as multiple attempts without success andcalling for help, which was the most com-mon complication (22%). More than twofailed punctures were significantly asso-ciated with an increased complicationrate.

Figure 1. B-scan depiction of a puncture of an adult left internal (Int.) jugular vein for central venous access. The tip of the needle can be seen to beintravascular after penetrating the wall of the internal jugular vein, which is slightly compressed.

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Mechanical Complications ofCentral Venous Catheterizationin Pediatric Patients

In children, Stenzel et al. (22) demon-strated a 3.7% complication rate for cath-eterization of the femoral vein comparedwith a rate of 7.3% for nonfemoral access.Previous cardiac catheterization compli-cated femoral vein puncture and in-creased the complication rate when thesame site was punctured (23). A low com-plication rate was reported by Johnson etal (24). In this retrospective survey, theoverall complication rate was 3.1% (1,435central venous catheter insertions). Re-ports of complication rates of subclavianvein catheterization in pediatric popula-tions range from 3% to 34% (22, 25, 26).Citak et al. (27) concluded that the sub-clavian approach for central venous ac-cess in children is a safe procedure. Of156 central venous catheters, the subcla-vian vein was chosen for venous access148 times, with an overall arterial punc-ture rate of 12.8%. As in adults, the IJVprovides a relatively reliable and usefulaccess site. Hematoma and arterial punc-tures were the most frequent complica-tions of IJV catheterization (28), followed,to a lesser extent, by pneumothorax. An-atomic variations of the common carotidartery (CCA) and the IJV and the smallerdiameter and lesser depth of the IJV mayaccount for failed punctures in children(28–30). Especially for IJV access, thereare some publications that demonstratedfewer complications in children whentwo-dimensional ultrasound (B-scan) wasused (31).

Position of the Internal JugularVein

Many different techniques for IJV can-nulation do exist, but palpation of the

CCA is a common procedure. The CCAusually lies directly under the medial partof the sternocleidomastoid muscle. Nee-dle insertion, slightly lateral to the ca-rotid pulse and above the angle of thesternocleidomastoid muscle with ad-vancement toward the ipsilateral nipple,reduces the risk of accidental arterialpuncture. Unfortunately, this procedureis not foolproof. Figure 2 shows examplesof anatomic variation in the position ofthe IJV based on ultrasound examinations(36–40); Table 2 provides details. Figure3 demonstrates an atypical vein medial tothe CCA.

The ultrasound findings of Forauerand Glockner (41) revealed an 18% totalocclusion rate of the IJV in patientsscheduled for dialysis catheter place-ment. IJV occlusion (thrombosis) in-creases complication rates because ofboth failed “dry” punctures and subse-quent deviation of the presumed optimalpuncture site and direction (Fig. 4). Inthe authors’ opinion, these marked differ-

ences in reported position of the IJV inregard to the CCA indicate that a reliableand constant anatomic position of the IJVdoes not exist. Even an anterolateral ap-proach carries the risk of accidental arte-rial puncture. Two-dimensional, ultra-sound-guided, real-time puncture ofveins demonstrates how the needle tipcompresses the vein’s wall without reallypenetrating it (Fig. 1 shows a successfulpuncture). A consequent deeper advance-ment (no aspiration of blood) can resultin penetrating the artery through thevein.

Location and successful cannulationof the IJV depend on a number of factors,including the size of the IJV, intravascu-lar volume status, and the degree of pres-sure exerted by the ultrasound probe onthe patient. Head rotation and patientpositioning are further factors influenc-ing the procedure of cannulation and ul-trasound detection (42, 43).

In patients undergoing surgery undergeneral anesthesia with a laryngeal mask

Table 1. Rates of mechanical complications for central venous catheterization

Access Complications

Internal Jugular Vein, % Subclavian Vein, % Femoral Vein, %

Overall Range, %Adult Pediatric Adult Pediatric Adult Pediatric

Arterial puncture 5 0–26.7 3.2–4.9 5.1–6.6 7.1–15 6.3–12.8 0–26.7Pneumothorax 0 0 1.5–2.8 1.3–2.5 NA NA 0–2.8Hemothorax 0 0 0.5 1.2 NA NA 0–1.2Failed puncture 25 20–39.1a 12 9.9 15–37 No data 9.9–39.1Catheter malposition No data 20 No data 2.2–16.1 No data 4.7 0–20Other severe No data No data No data No data 1.4 No data 0–1.4Other minor No data No data 6.9 No data 1.4–4.4 No data 1.4–6.9Overall range 0–32.5 0–39.1 0.5–12 1.2–16.1 1.4–37 4.7–12.8 0–39.1

NA, not applicable.aAccounts for children �1 yr of age and/or �10 kg of body weight. Data collection from references 18–21, 24, 25, 27, 32–35.

Figure 2. Prevalence of occurrence of variation in the position of the internal jugular vein in relationto the common carotid artery (CA). Circles describe reported positions of the internal jugular vein.Data extracted from references 36–40. *jugular vein overlaps �75% of the CA. Table 2 provides detailsand the number of patients in the referenced studies.

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inserted, puncture of the IJV can be dif-ficult because of difficulty in palpatingthe CCA and displacement of the sterno-cleidomastoid muscle (44). A study ofTakeyama et al. (45) demonstrated that

ventilation with a laryngeal mask in-creased the overlapping of the IJV andCCA when the head was in 30 degrees ofrotation to the opposite site of puncture.This was reported at the high of the mid-

point of the mastoid process and the in-tersection of the clavicular and sternalhead of the sternocleidomastoid musclebut not in the supraclavicular vicinity.Overlapping of the IJV and CCA is asso-

Figure 3. Depiction of the common carotid artery of a healthy adult patient. A small atypical vein is located medial to the common carotid artery.

Table 2. Frequencies given as percentage of position of the internal jugular vein relative to the common carotid artery

Reference

Position of the Internal Jugular Vein Relative to the Common Carotid Artery (%)Not Visibleor OccludedMedial Anterior Antero-Lateral Lateral Far Lateral Posterior

Denys, n � 200 (40) 2 92 1 2.5 3Turba, n � 188 (37) R 0.5 R 4 R 16 R 80

L 0.5 L 6 L 9 L 84Gordon, n � 659 (36) 5.5Caridi, n � 80 (38) 16 71 4 9Forauer, n � 100 (41) 18Brederlau, n � 64 (46) 39a

Troianos, n � 1009 (39) 54.3b 39.3 6.4

R, right site; L, left site.aInternal jugular vein overlaps �50% the common carotid artery; binternal jugular vein overlaps common carotid artery �75%.

Figure 4. B-scan of the right jugular angle in an adult patient. Ultrasound was used for placing a central catheter after three failed punctures. The imageshows an intravenous thrombosis of the jugular vein that almost completely fills the intravascular lumen. Int., internal.

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ciated with an increased risk of arterialpuncture. Takeyama et al. (45) concludedthat ultrasound guidance should be usedfor IJV cannulation.

Ultrasound for Atypical CentralVenous Access

In infants and obese or edematous pa-tients, intravenous access of peripheralveins can be a challenge. The axillary,basilic, and cephalic veins are alternativeaccess sites for peripheral or central ve-nous catheterization (47–49). Veins inthe cubital fossa are frequently throm-bosed in intravenous drug abusers, pa-tients with multiple operations and hos-pitalizations, and in those with frequentvenous cannulations or peripherallyplaced central venous catheters. Longitu-dinal scanning of the basilic and cephalicvein allows both visualization of the cath-eter and guidewire insertion. This can behelpful if difficulties are encounteredwith advancing the catheter (e.g., throm-bosis) (47). To reduce complications (e.g.,nerve damage and arterial puncture), de-piction of the median nerve and the bra-chial artery should be obtained in trans-verse section when cannulation of thebasilic vein is performed.

Cannulation of the axillary vein can bean alternative to subclavian vein punc-ture. Axillary vein access is easier to vi-sualize with ultrasound because of themore laterally located puncture site andthe consequently greater distance be-tween clavicle and ultrasound probe (50).Complication rates of guidewire andcatheter misplacement are comparablewith the traditional landmark technique

(49). Although results of large prospec-tive studies for axillary vein access arelacking, complications like arterial punc-tures with ultrasound-guided access ofthe axillary vein were reported to belower than when using the landmarktechnique (0 to 1.5%) (49, 50). High-resolution ultrasound (�10 MHz) is ex-cellent for veins located in the cubitalfossa because surrounding structures caneasily be identified (e.g., nerves). In con-trast, access of the deeply located axillaryvein is preferably performed with 5- to7.5-MHz ultrasound probes. This is par-ticularly necessary for the obese patient.Due to the deep location, difficulties withintroducing the guidewire or cathetercan also occur because of the steep angleof needle and vein.

Ultrasound-Guided ArterialCatheterization

A prospective, randomized study byLevin et al. (51) compared ultrasound-guided radial artery cannulation vs. thepalpation technique. Two-dimensionalultrasound-guided catheterization wassuperior to palpation for first insertionattempt (p � .03) and number of at-tempts (p � .003). Although the time forsuccessful cannulation was longer in theultrasound group (26.1 secs vs. 17.3 secs,p � .0001), mean time for each patientwas shorter (55.5 secs vs. 111.5 secs, notsignificant). Furthermore, many of theparticipating anesthesiologists were us-ing ultrasound for the first time for arte-rial catheter insertion, thus demonstrat-ing the ease of use of this technique.

Puncture of the radial artery is fre-quently chosen because of the dual arte-rial supply to the hand by the ulnar artery(Fig. 5, radial artery; Fig. 6, axillary ar-tery). After multiple unsuccessful at-tempts at radial artery cannulation, vaso-spasm or hematoma formation may makesubsequent successful catheterization al-most impossible. Sandhu and Patel (52)have described a method using two-dimensional ultrasonography for radialartery access at the mid-forearm as a res-cue technique. The artery can be identi-fied beneath the brachioradialis muscle atthe mid-forearm level. Transversal orlongitudinal images were used for cannu-lation. The needle can be redirected safelyfor best viewing results, because nonerves are adjacent to the artery at thislevel.

Similar to the adult study by Levin etal. (51), a prospective, randomized trialby Schwemmer et al. (53) demonstrated aclear benefit of ultrasound use for radialarterial cannulation in children. Ultra-sound-guided catheterization was supe-rior to the traditional palpation methodfor successful first attempt (p � .05) andtotal number of attempts (p � .05). Incontrast to the adult findings of Levin etal. (51), time for successful cannulationwas shorter in children.

Discussion and Examples ofClinical Application

A meta-analysis of ultrasound guid-ance for central venous catheter place-ment, published in 1996 by Randolph etal. (54), included eight randomized, con-trolled trials. This study group concluded

Figure 5. Cannulation of the radial artery in an adult patient. Longitudinal scan. Depiction of the proximal and distal intima.

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that the use of ultrasound significantlyreduced “internal jugular and subclaviancatheter placement failure” comparedwith the traditional landmark method(relative risk, 0.32; 95% confidence inter-val, 0.10–0.45). Complications of cathe-terization and the number of catheteriza-tion attempts were also reduced.Randolph et al. (54) included Doppler ul-trasound-guided studies in their analysis.Hind et al. (55) subsequently excludedthese trials in another meta-analysis.Data from 18 studies were evaluated.Two-dimensional ultrasound showed aclear benefit for central venous accesswhen compared with the landmark meth-ods. This technique was more effective inavoiding failures in the first attempt, forfailed catheter placements, and for com-plications of venous cannulation. Evi-dence for IJV access was good but sparsefor subclavian or femoral venous access.We have found no study of ultrasound-guided cannulation of the innominatevein (Fig. 7). Only one study reported a

significantly higher success rate for IJVcannulation in the landmark group whencompared with two-dimensional ultra-sound (56). This study has been com-mented on by Grau et al (57).

Disadvantages to the use of ultrasoundmust also be mentioned. There can be atime-consuming learning process (espe-cially for the free-hand technique). Thereis an initial time demand to power and setup the device and to cover the probe witha sterile sheath. There is a real expense ofthe ultrasound devices and valid concernsthat operators will become less experi-enced in the field of vascular access usingthe traditional landmark technique.

We think that all these potential dis-advantages are easily outweighed by theabove-mentioned advantages: visualiza-tion of the precise target location, visu-alization of needle progression, reducedpuncture attempts, improved successrates, minimizing or preventing punc-ture and catheter-related complications,and control of catheter location. In addi-

tion, we would like to emphasize poten-tial efficiencies to the process in the op-erating room or intensive care unit.Despite an increased lead time for ultra-sound usage, the effective time for suc-cessful cannulation can be shortened, es-pecially for those with difficult vascularaccess.

Perspectives

As mentioned in the previously dis-cussed meta-analysis, more clinical trialsare required to prove effectiveness, espe-cially for access sites other than the IJV.To compare results of clinical investiga-tions for ultrasound and vascular access,not only the number of success rates andcomplications should be reported butalso the number of the puncture attemptsthrough skin, number of needle advance-ments, patient anatomy, positioning ofpatient and ultrasound probe, and thenumber of previous catheterizations.Furthermore, reports of lesions of the

Figure 6. Cannulation of the axillary artery (A.). Cross-sectional scan with depiction of the median, radial and ulnar nerve. White spot represents the needletip. The longitudinal scan shows a catheter inserted by Seldinger technique.

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vascular intima or history of vascular dis-ease could be useful to demonstrate thebeneficial aspects of ultrasound usage. Itshould be noted that medical materialused for venous cannulation still is notoptimized for ultrasound visualization.We believe that there is a potential fortechnical improvements in the needlesand catheters used for ultrasound imag-ing.

CONCLUSION

Ultrasound-guided vascular access hasbeen shown to shorten time of the pro-cedure, reduce the number of failedpuncture attempts, and to minimizecomplications of central venous catheter-ization. Ultrasound combines the punc-ture process with diagnosis and detectionof anatomic variations, lesions, and com-plications, which makes it a powerful toolfor vascular access. Patients thus benefitfrom a reduced rate of complications.

Fast and successful central venous accessthus lowers costs by reducing complica-tions and optimizing the process andconduct in the operating room and inintensive care units [32–35, 46].

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