Right supraclavicular fossa ultrasound view for real-time central venous catheter tip positioning in adult patients: A systematic review

Abstract

Background and Aims:

Central venous catheter (CVC) tip placement within the lower third of the superior vena cava or at the cavo-atrial junction is vital to avoid complications. Chest radiograph (CXR), the standard for post-procedural confirmation, has limitations, including radiation exposure and delay in malposition diagnosis. Ultrasonography (USG) enables real-time tip confirmation. This review aimed to consolidate evidence on the use of right supraclavicular fossa ultrasound view in CVC tip position confirmation in adult patients using radiographic imaging as a reference.

Methods:

A systematic literature search of Medline via Pubmed, Scopus, Google Scholar, and ResearchGate was conducted from database inception until 14 May 2024. Eligible studies included adults undergoing USG-guided CVC insertion, comparing real-time right supraclavicular fossa ultrasonographic view with CXR or fluoroscopy for optimum CVC tip positioning. Outcomes included correct CVC placement, malposition detection, malposition correction, and complications.

Results:

From 1,865 records, five observational studies met the inclusion criteria (sample size: 252). Correct CVC tip positioning was confirmed radiographically in 99.16% of the cases. Three studies reported a pooled malposition rate of 7.89% using the right supraclavicular fossa ultrasound view. Among the pooled malpositions, 87.33% were corrected intra-procedurally using the right supraclavicular fossa ultrasonographic view. No complications occurred during repositioning.

Conclusion:

The right supraclavicular fossa ultrasound view appears to be useful in real-time confirmation of CVC tip position and facilitates intra-procedural correction of malposition. However, the findings are limited by the small overall sample size, heterogeneity among included studies, and the absence of diagnostic accuracy.

INTRODUCTION

Central venous catheter (CVC) insertion is a routine yet critical procedure. Accurate placement of the CVC tip within the lower third of the superior vena cava (SVC) or at the cavo-atrial junction is essential to ensure optimal catheter function and to minimise complications. Malpositioned catheter tips are associated with a range of adverse events, including catheter dysfunction, arrhythmias, thrombosis, vascular erosion, and potentially fatal extravasation of infusates into non-targeted vessels.[1,2,3] The rates of catheter malposition vary from 3.3% to 13.4%, even when inserted by experienced operators.[3,4,5,6]

Post-procedural confirmation of CVC tip location has traditionally relied on chest radiograph (CXR), which remains the most widely accepted method. However, a CXR is not without limitations, including radiation exposure, delays in malposition diagnosis, and additional cost. Furthermore, multiple studies have raised concerns about the reliability of radiographic anatomical landmarks for confirming tip position, especially in detecting subtle malpositions.[7,8,9,10,11] The use of ultrasonography (USG) for procedure and post-procedural confirmation of CVC tip position has gained attention due to advantages such as avoidance of radiation, reduced patient transport, immediate detection of malposition, and the opportunity to perform real-time repositioning.[12,13] Various ultrasound windows, such as the right supraclavicular fossa, subcostal, parasternal, and suprasternal approaches, have been explored.[14,15,16,17] Among these, the right supraclavicular fossa view has been suggested as a technically feasible approach; however, existing evidence is limited to small cohorts or specific clinical settings, and a consolidated evaluation of its use is still lacking.[15,16,17] Thus, we aimed to synthesise current evidence on the use of the right supraclavicular fossa ultrasound view for real-time confirmation of CVC tip positioning in adult patients. The primary objective was to determine the percentage of correct CVC tip placement achieved using the right supraclavicular fossa ultrasound view, as confirmed on post-procedural CXR. The secondary objectives were to assess the percentage of catheter malpositions detected intra-procedurally using this ultrasound view, the proportion of malpositioned catheters that were successfully corrected under ultrasound guidance with confirmation by CXR or fluoroscopy, and the incidence of complications associated with USG-guided catheter repositioning.

METHODS

Search strategy

The protocol for this systematic review and meta-analysis was prospectively registered in the International Prospective Register of Systematic Reviews (PROSPERO) under registration number CRD42023455597. This review complied with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. A completed PRISMA checklist is provided in Supplementary Table S1.

Table S1.

Compliance to PRISMA checklist

Section/topic		#		Checklist item		Reported on page #
Title
Title		1		Identify the report as a systematic review, meta-analysis, or both.		1
ABSTRACT
Structured summary		2		Provide a structured summary including, as applicable: background; objectives; data sources; study eligibility criteria, participants, and interventions; study appraisal and synthesis methods; results; limitations; conclusions and implications of key findings; systematic review registration number.		3-4
INTRODUCTION
Rationale		3		Describe the rationale for the review in the context of what is already known.		5
Objectives		4		Provide an explicit statement of questions being addressed with reference to participants, interventions, comparisons, outcomes, and study design (PICOS).		6
METHODS
Protocol and registration		5		Indicate if a review protocol exists, if and where it can be accessed (e.g., Web address), and, if available, provide registration information including registration number.		7
Eligibility criteria		6		Specify study characteristics (e.g., PICOS, length of follow-up) and report characteristics (e.g., years considered, language, publication status) used as criteria for eligibility, giving rationale.		7
Information sources		7		Describe all information sources (e.g., databases with dates of coverage, contact with study authors to identify additional studies) in the search and date last searched.		7
Search		8		Present full electronic search strategy for at least one database, including any limits used, such that it could be repeated.		7
Study selection		9		State the process for selecting studies (i.e., screening, eligibility, included in systematic review, and, if applicable, included in the meta-analysis).		8
Data collection process		10		Describe method of data extraction from reports (e.g., piloted forms, independently, in duplicate) and any processes for obtaining and confirming data from investigators.		8
Data items		11		List and define all variables for which data were sought (e.g., PICOS, funding sources) and any assumptions and simplifications made.		7-8
Risk of bias in individual studies		12		Describe methods used for assessing risk of bias of individual studies (including specification of whether this was done at the study or outcome level), and how this information is to be used in any data synthesis.		9
Summary measures		13		State the principal summary measures (e.g., risk ratio, difference in means).		8-9
Synthesis of results		14		Describe the methods of handling data and combining results of studies, if done, including measures of consistency (e.g., I2) for each meta-analysis.		8-9
Risk of bias across studies		15		Specify any assessment of risk of bias that may affect the cumulative evidence (e.g., publication bias, selective reporting within studies).		9
Additional analyses		16		Describe methods of additional analyses (e.g., sensitivity or subgroup analyses, meta-regression), if done, indicating which were pre-specified.		9
RESULTS
Study selection		17		Give numbers of studies screened, assessed for eligibility, and included in the review, with reasons for exclusions at each stage, ideally with a flow diagram.		11
Study characteristics		18		For each study, present characteristics for which data were extracted (e.g., study size, PICOS, follow-up period) and provide the citations.		11
Risk of bias within studies		19		Present data on risk of bias of each study and, if available, any outcome level assessment (see item 12).		12
Results of individual studies		20		For all outcomes considered (benefits or harms), present, for each study: (a) simple summary data for each intervention group (b) effect estimates and confidence intervals, ideally with a forest plot.		11-12
Synthesis of results		21		Present results of each meta-analysis done, including confidence intervals and measures of consistency.		12
Risk of bias across studies		22		Present results of any assessment of risk of bias across studies (see Item 15).		12
Additional analysis		23		Give results of additional analyses, if done (e.g., sensitivity or subgroup analyses, meta-regression [see Item 16]).		NA
DISCUSSION
Summary of evidence		24		Summarise the main findings including the strength of evidence for each main outcome; consider their relevance to key groups (e.g., healthcare providers, users, and policy makers).		13
Limitations		25		Discuss limitations at study and outcome level (e.g., risk of bias), and at review-level (e.g., incomplete retrieval of identified research, reporting bias).		15-16
Conclusions		26		Provide a general interpretation of the results in the context of other evidence, and implications for future research.		16
FUNDING
Funding		27		Describe sources of funding for the systematic review and other support (e.g., supply of data); role of funders for the systematic review.		2

A comprehensive literature search was conducted to identify studies evaluating the utility of the right supraclavicular fossa ultrasound view for real-time CVC tip positioning in adult patients. The electronic databases MEDLINE via PubMed, Scopus, Google Scholar, and ResearchGate were systematically searched for studies published from database inception to 14 May 2024 using a predefined search strategy. The search strategy used a combination of Medical Subject Headings (MeSH) and free-text keywords, including “central venous catheter”, “CVC tip”, “ultrasound”, “supraclavicular fossa”, and “chest X-ray”. Boolean operators (“AND”, “OR”) were applied to refine search sensitivity. The full search strategy for each database is detailed in Supplementary Files 1a and 1b.

Study selection

Studies were considered eligible if they fulfilled the following criteria: (1) enroled adult patients (aged ≥18 years) undergoing USG-guided central venous catheterisation, (2) used real-time right supraclavicular fossa USG to visualise the catheter or guidewire tip during insertion, and (3) used postprocedural CXR or fluoroscopy as the reference standard to confirm catheter tip position. Both prospective and retrospective observational studies were included if they reported extractable outcome data related to CVC tip placement accuracy, malposition detection, correction, or complications. We excluded duplicate publications, case reports, case series, conference proceedings, review articles, and studies not conducted on human participants. Only studies published in English were included.

All retrieved articles were imported into the Rayyan software. Duplicate entries were removed, and the most recent versions of studies were retained for screening. Two independent reviewers (RAD and AM) screened the titles and abstracts for eligibility. Full-text articles were obtained for all studies meeting initial criteria or requiring clarification. Any disagreements were resolved by a third reviewer (IM). Reference lists of included studies were also screened for additional eligible studies. Study authors were contacted where necessary to obtain missing outcome data.

Data extraction

A pretested data extraction spreadsheet was used to extract the following information: first author, year of publication, study design, setting, sample size, demographic characteristics, catheter insertion site and type, modality used for tip confirmation, and outcomes. The primary outcome was the incidence/percentage of correct CVC tip placement [(Total number of correct CVC location on post-procedural CXR or fluoroscopy/Total CVC insertions) x100]. Secondary outcomes were (i) incidence/percentage of CVC malposition detected during intraprocedural right supraclavicular fossa USG [(Total number of malpositioned CVC tips identified through right supraclavicular fossa ultrasound/Total CVC insertion) x100], (ii) incidence/percentage of malpositioned CVC corrected during right supraclavicular fossa ultrasound which was confirmed by CXR or fluoroscopy [(Total number of malpositioned CVC tips corrected during right supraclavicular fossa ultrasound/Total number of malpositioned CVC tips detected during right supraclavicular fossa ultrasound) x100], and (iii) Incidence of any complication during repositioning of malpositioned CVC.

Two reviewers (RGM and SS) independently assessed the methodological quality and risk of bias using the National Institutes of Health (NIH) Quality Assessment Tool for observational cohort and cross-sectional studies. The tool consists of 14 domains that evaluate research question clarity, population selection, sample size justification, outcome and exposure measurement, follow-up adequacy, and confounding control. Each item was rated as “yes”, “no”, or “cannot determine”. Disagreements were resolved through discussion with a third reviewer (IM). The NIH tool was selected for its suitability in evaluating non-randomised diagnostic accuracy studies.

A proportional meta-analysis was conducted to pool summary estimates of the primary and secondary outcomes. The DerSimonian–Laird random-effects model was applied to account for inter-study variability. Summary proportions and their corresponding 95% confidence intervals (CIs) were calculated. Statistical heterogeneity was assessed using the I² statistic, with values above 50% indicating substantial heterogeneity. All analyses were performed using STATA version 18 (Stata Corp LLC, College Station, Texas, USA). This software was used to calculate pooled estimates, generate forest plots, and assess heterogeneity. Due to the small number of studies and clinical heterogeneity, no subgroup or sensitivity analyses were performed.

This study was based entirely on previously published data and did not involve the collection of new data from human or animal subjects. Therefore, institutional ethical approval and informed consent were not required. All included studies were presumed to have obtained appropriate ethical clearances.

RESULTS

A total of 1,865 potentially relevant articles were identified through database searches. After removing 286 duplicates, 1,579 unique records were screened based on titles and abstracts. Of these, 19 full-text articles were assessed for eligibility, and five studies met the inclusion criteria [Figure 1].

Figure 1.

Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flow diagram

The reasons for excluding the other full-text articles are detailed in Supplementary Table S2. All five included studies were single-centre observational studies, published between 2015 and 2021, and involved adult patients undergoing central venous access procedures.[15,16,17,18,19] The total pooled sample size was 252 participants. Across all studies, male participants constituted at least 50% of the sample, although exact sex-specific distributions were not reported. The mean age of participants ranged from 57 to 72.5 years, consistent with a population of middle-aged to elderly adults. With respect to catheter type, four studies involved the placement of CVC, while one study reported peripherally inserted central catheters (PICCs).[15,16,17,18,19] The CVC insertion sites included the right subclavian vein in two studies, and the right internal jugular vein was used in one study.[15,16,17] The right external jugular vein was used in one study.[18] The approach to PICC was via either the right or left brachiocephalic vein.[19] All studies used a micro-convex USG probe. All studies aimed for the optimum position of the guidewire to be in the lower part of the SVC.

Table S2.

List of articles excluded from the review with reasons

Author		Title		Journal		Year		Reason for exclusion
Prasad R et al.		Supraclavicular or infraclavicular subclavian vein: Which way to go- A prospective randomized controlled trial comparing catheterisation dynamics using ultrasound guidance.		Indian Journal of Anaesthesia		2020		Unsuitable Methodology
Panda et al.		Evaluation of the Efficacy of Ultrasound in Detecting Correct Placement of Central Venous Catheter and Determining the Elimination of the Need for Chest Radiography		Journal of Cardiac Critical Care		2021		Unsuitable Methodology
Liu, S et al.		Tip orientation under real-time point-of-care neck ultrasonic monitoring is advantageous in peripherally inserted central catheter procedures: A retrospective cohort study		Emergency and Critical Care Medicine -		2023		Unsuitable Methodology
Miccini M et al.		Ultrasound-Guided Placement of Central Venous Port Systems via the Right Internal Jugular Vein: Are Chest X-Ray and/or Fluoroscopy Needed to Confirm the Correct Placement of the Device?		World Journal of Surgery		2016		Unsuitable Methodology
Kim SC et al.		Thesupraclavicularfossa ultrasound view for central venous catheter placement and catheter change over guidewire.		Journal of Visualised Experiments		2014		Review article
Marano L et al.		Peripherally inserted central catheter tip position: a novel empirical-ultrasonographical index in a modern surgical oncology department.		Annals of Surgical Oncology		2014		Unsuitable Methodology
Durán-Briones G et al.		Central vascular access guided by high-resolution ultrasonography for invasive intra anaesthetic monitoring.		Cirugia y cirujanos -		2010		Non-English language
Cavatorta F et al.		Ultrasound-guided cannulation and endocavitary electrocardiography placement of internal jugular vein catheters in uremic patients: the importance of routine chest X-ray evaluation.		The Journal of Vascular Access		2001		Unsuitable Methodology
Kim SC et al.		A Supraclavicular Fossa Ultrasound Window for Central Venous Catheter Positioning		Anaesthesia and Analgesia		2017		Commentary
William D et al.		A randomized, controlled trial evaluating postinsertion neck ultrasound in peripherally inserted central catheter procedures		Critical Care Medicine		2009		Unsuitable Methodology
Zanobetti M et al.		Verification of correct central venous catheter placement in the emergency department: comparison between ultrasonography and chest radiography.		Internal and Emergency Medicine		2013		Unsuitable Methodology
Matsushima et al.		Detection of central venous catheter insertion-related complication using bedside ultrasound: the CVC sono.		The Journal of Trauma: Injury, Infection, and Critical Care		2011		Technical notes
Vezzani A et al.		Ultrasound localization of central vein catheter and detection of postprocedural pneumothorax: an alternative to chest radiography.		Critical Care Medicine		2010		Unsuitable Methodology
Brusasco et al.		Ultrasound-guided central venous cannulation in bariatric patients.		Obesity Surgery		2009		Unsuitable Methodology

Post-procedural CXR was used to confirm the position of the catheter tip in all five studies. Additionally, one study also incorporated intracardiac electrocardiography (ECG) and transoesophageal echocardiography (TEE), while another study used fluoroscopy as a confirmatory modality [Table 1].[16,19]

Table 1.

Demographic characteristics of included studies

Author		Study design		Total Number of patients		CVC/PICC		Approach		USG Probe used		Optimal/Acceptable position on CXR		Confirming post-procedure tip position
Adrian, 2021[15]		Observational study		103		CVC		Right Subclavian		Micro-convex probes		Lower SVC/at the cavo-atrial junction or upper part of the right atrium/in the proximal SVC (aligned with the vessel)		CXR
Se-Chan Kim, 2015[16]		Observational study		48		CVC		Right IJV		Micro-convex probes		Criteria not mentioned. The radiologists reported CVC positioning.		CXR, intracardiac ECG, TEE
Se-Chan Kim, 2016[17]		Observational study		20		CVC		Right Subclavian		Micro-convex probes		Criteria not mentioned. The radiologists reported CVC positioning.		CXR
Kosaka, 2018[18]		Observational study		62		CVC		Right EJV		Micro-convex probes		Anatomical relationship between the CVC tip and the carina		CXR
Kirkegaard, 2021[19]		Observational Study		19		PICC		Right and Left Arm		Micro-convex probes		Between the SVC-right atrial junction and the carina		CXR, Fluoroscopy

CVC: Central venous catheter; PICC: Peripherally inserted central catheter; CXR: Chest radiograph; ECG: Electrocardiography; TEE: Transoesophageal echocardiography; IJA: Internal jugular vein; EJV: External jugular vein; SVC: Superior vena cava

The primary outcome, defined as pooled correct catheter tip positioning confirmed by radiographic methods, was achieved in 99.16% (247/252) of cases (95% CI: 96.08 to 100.00), with moderate statistical heterogeneity across studies (I² =43.05%, P = 0.13) as shown in Figure 2. Among the secondary outcomes, three studies reported the proportion of CVC malpositions detected in real time using the right supraclavicular fossa ultrasound view.[15,18,19] The pooled malposition rate was 7.89% (27/252) (95% CI: 0.46 to 21.01), with substantial heterogeneity (I² = 86.77%, P = 0.00) [Figure 3]. Among the pooled detected malpositions, 87.33% (23/27) (95% CI: 69.72 to 98.84) were successfully corrected intra-procedurally under ultrasound guidance (I² = 0.00%, P = 0.64) [Figure 4]. No complications were reported during repositioning in any of the studies.

Figure 2.

Forest Plot: Proportion of correct CVC Tip placement on post-procedure chest radiograph. CI: Confidence interval

Figure 3.

Forest Plot: Proportion of malpositioned CVC tip detected during intraprocedural right supraclavicular fossa ultrasound. CI: Confidence interval

Figure 4.

Forest Plot: Proportion of corrected malpositioned CVC tip using right supraclavicular view. CI: Confidence interval

Most studies clearly described their objectives and study populations. In two studies, exposure was assessed prior to outcome ascertainment, and the study duration was adequate to support a temporal relationship.[15,16] Blinding of outcome assessors was reported in only one of the three studies where blinding was applicable.[15] Only two studies statistically adjusted for potential confounding variables.[15,16] A detailed description of the risk of bias assessment is presented in Table 2.

Table 2.

Risk of bias of the studies included in the systematic review and meta-analysis

Criteria		Adrian et al.; 2021[15]		Kim et al. 2015[16]		Kim et al.; 2016[17]		Kosaka et al.; 2018[18]		Kirkegaard et al.; 2021[19]
1. Was the research question or objective in this paper clearly stated?		Yes		Yes		Yes		Yes		Yes
2. Was the study population clearly specified and defined?		Yes		Yes		Yes		Yes		Yes
3. Was the participation rate of eligible persons at least 50%?		Yes		NR		Yes		Yes		Yes
4. Were all the subjects selected or recruited from the same or similar populations (including the same time period)? Were inclusion and exclusion criteria for being in the study prespecified and applied uniformly to all participants?		Yes		Yes		Yes		Yes		Yes
5. Was a sample size justification, power description, or variance and effect estimates provided?		Yes		Yes		Yes		Yes		Yes
6. For the analyses in this paper, were the exposure(s) of interest measured prior to the outcome(s) being measured?		Yes		Yes		No		No		No
7. Was the timeframe sufficient so that one could reasonably expect to see an association between exposure and outcome if it existed?		Yes		Yes		NA		NA		NA
8. For exposures that can vary in amount or level, did the study examine different levels of the exposure as related to the outcome (e.g., categories of exposure, or exposure measured as continuous variable)?		NA		NA		NA		NA		NR
9. Were the exposure measures (independent variables) clearly defined, valid, reliable, and implemented consistently across all study participants?		Yes		Yes		Yes		Yes		NA
10. Was the exposure(s) assessed more than once over time?		No		No		CD		No		No
11. Were the outcome measures (dependent variables) clearly defined, valid, reliable, and implemented consistently across all study participants?		Yes		Yes		Yes		Yes		NA
12. Were the outcome assessors blinded to the exposure status of participants?		Yes		CD		NA		NA		NR
13. Was loss to follow-up after baseline 20% or less?		Yes		Yes		NA		Yes		No
14. Were key potential confounding variables measured and adjusted statistically for their impact on the relationship between exposure(s) and outcome(s)?		Yes		Yes		No		No		No

CD: Cannot determine; NA: Not applicable; NR: Not reported

DISCUSSION

This systematic review and meta-analysis evaluated the use of real-time right supraclavicular fossa USG in confirming and correcting the CVC tip position. Across five observational studies involving a total of 252 adult patients, the pooled proportion of correct CVC tip placement was 99.16%. Mispositioned tips were identified in 7.89% of cases during the procedure using the same ultrasound view, of which 87.33% were successfully corrected in real time without any complications.

Traditionally, confirmation of CVC tip position has relied on post-procedural CXR owing to its widespread availability and familiarity among clinicians. However, several studies have highlighted that the CXR often lacks the anatomical precision needed to identify the exact location of the catheter tip, particularly in relation to the superior vena cava–right atrial (SVC–RA) junction. Bedside radiographs showed poor concordance with TEE for intra-atrial catheter tip localisation, whereas TEE was a more reliable reference for electrocardiographically guided catheter placement.[10,11,20] Although alternative techniques such as intracardiac ECG and TEE offer reasonable diagnostic accuracy, their use is limited by invasiveness, cost, and availability.

Real-time USG has gained interest as an intra-procedural adjunct for CVC tip position assessment.[12,13,14,15,16,17] The right supraclavicular fossa is an ideal acoustic window to visualise the confluence of the internal jugular and subclavian veins into the brachiocephalic vein and SVC [Supplementary File: Figure S1 ^{(1.3MB, tif)} ]. This sonographic view allows for dynamic observation of guidewire or catheter advancement, enabling the prompt identification of misdirection into tributaries, such as the internal thoracic or azygos veins. Compared to transthoracic or subcostal echocardiographic views, the supraclavicular approach appears to be ergonomic. It can be performed with the patient in a neutral supine position, facilitating its use in emergency, perioperative, and intensive care settings.[21]

Several studies support the USG-based methods for verifying the tip. The saline flush test, using dynamic sonographic visualisation of agitated saline, showed comparable catheter placement with accuracy to CXR.[22,23] A systematic review and meta-analysis showed that contrast-enhanced ultrasound (CEUS) is a safe alternative to post-procedural radiography.[13] Another study demonstrated equivalent performance of CEUS in the subcostal bicaval view and TEE for catheter malposition detection.[24]

The clinical significance of CVC malposition is well documented. Improper tip placement in non-central vessels can lead to catheter wedging, vascular erosion, thrombosis, catheter dysfunction, and retrograde infusion into cranial circulation.[4,25,26] Walshe et al.[25] reported vascular erosion in patients receiving parenteral nutrition due to malpositioned catheters. In a 5-year prospective study, Schummer et al.[4] identified a 6.7% incidence of malposition among 1,794 catheterisations, with the highest rates associated with left internal jugular access. Ruesch et al.[26] reported higher malposition rates with subclavian access than internal jugular vein cannulation (9.3% vs 5.3%, respectively).

In the present meta-analysis, the pooled malposition rate of 7.89% aligns with prior observational data, despite the use of USG-guided insertion in all included studies.[3,5,6] The observed heterogeneity (I² = 86.77%) may reflect small, single-centre observational studies, variability in operator experience, patient settings (e.g., surgical versus intensive care unit), anatomical access routes, and definitions of malposition on CXR. Notably, 87.33% of malpositioned tips were successfully corrected under real-time sonographic guidance using the right supraclavicular fossa view, with no reported complications. This ability to identify and rectify malpositions during the procedure underscores the practical advantage of dynamic USG over delayed post-procedural confirmation.

Using real-time right supraclavicular fossa USG for CVC tip confirmation offers clinical benefits. Allowing immediate visualisation of the catheter tip during insertion enables prompt detection and correction of malpositions, reducing the risk of complications and obviating the need for repeat cannulation. This approach would also minimise dependency on post-procedure CXR. Its integration into clinical practice may enhance procedural efficiency. Additionally, in a clinical setting where radiographic facilities may be unavailable or delayed, ultrasound-guided confirmation offers an alternative.

The strengths of this review include adherence to a registered protocol, compliance with PRISMA 2020 guidelines, use of a robust search strategy, and pooled analysis using a random-effects model. The findings are supported by consistent trends across all included studies, and statistical heterogeneity was quantified using I² values.

However, several limitations must be acknowledged. The analysis was restricted to five single-centre small observational studies, limiting the generalisability of findings. The inclusion of only five studies restricts the precision of heterogeneity estimates such as I² and τ², rendering them statistically unstable. Moreover, conventional methods such as the DerSimonian–Laird model with Freeman–Tukey double arcsine transformation are suboptimal for extreme proportions like those observed in our analysis, potentially producing invalid CIs exceeding 100%. To address this, we employed a mixed-effects logistic regression model with marginal estimation using the “metapreg” package in Stata, which offers more appropriate modelling of high-incidence proportions within a bounded probability space. Nevertheless, the limited number of studies continues to constrain the robustness of between-study variance estimates and should be considered when interpreting the pooled findings.

The pooled estimate for malposition (7.89%) revealed substantial heterogeneity (I² = 86.77%), which may be attributed to possible variations in operator experience with USG and patient settings (elective versus emergency). This review included CVC access through either the internal jugular vein or the subclavian vein, accessed on either the left or right side. We have also included one study on PICC as the clinical endpoint for catheter tip positioning is identical for both PICCs and CVCs, namely, placement at the lower third of the SVC or at the cavo-atrial junction. Consequently, the methods used for tip localisation and their clinical implications would be comparable. However, we were unable to perform a subgroup analysis due to the limited number of studies. The definitions of malposition on CXR also varied between the studies. Blinding of outcome assessors was inconsistently reported, and only two studies employed statistical adjustment for confounders. All included studies aimed for real-time USG visualisation of the guidewire tip and malposition correction; thus, data for sensitivity and specificity were not available. Although no complications were reported during correction of the malpositioned tip, the safety profile should be confirmed in larger, well-designed multicentre trials. Future studies should also evaluate learning curves and reproducibility to support integration in clinical settings.

CONCLUSION

This systematic review and meta-analysis provides preliminary evidence supporting the use of the right supraclavicular fossa USG view as a real-time method for confirming and correcting CVC tip position. However, current evidence is limited by small observational studies with variable methodological quality. Future large, multicentre prospective studies using standardised ultrasound protocols with validated outcome definitions are needed.

Author contributions

IM: Concept, study screening, data acquisition, risk of bias assessment, manuscript editing. RGM: Data acquisition, risk of bias assessment, manuscript preparation. AL: Statistical analysis, manuscript preparation, manuscript editing. RAD: Literature search, study screening, manuscript review. AM: Study screening, manuscript preparation. SS: Data acquisition, risk of bias assessment. All the authors have participated in the review, drafting and final approval of the manuscript.

Disclosure of use of artificial intelligence (AI)-assistive or generative tools

Grammarly software was used for language and grammar checking. No AI tool was used during manuscript preparation.

Declaration of use of permitted tools

No proprietary tools requiring permission were used in this study.

Supplementary material

This article has supplementary material which can be accessed at the following link - https://links.lww.com/IJOA/A90.

Conflicts of interest

There are no conflicts of interest.

Figure S1

(a) USG image of the right supraclavicular fossa view showing a guidewire in the lower part of the superior vena cava. (b) Schematic diagram for the Right supraclavicular fossa ultrasound view. SVC: Superior vena cava; Rt IJA: Right internal jugular vein; Rt SCV: Right subclavian vein; Rt BCV: Right brachiocephalic vein; Lt BCV: Left brachiocephalic vein; RPA: Right pulmonary artery

Funding Statement

Nil.

SUPPLEMENTARY FILES

1. Search strategy

1a. Study selection criteria

• Inclusion criteria:

  • Language: Articles in English.

  • Year of publication: Studies published up to 14 May 2024

  • Data type: Primary research or secondary data analysis of the available data.

  • Study design: All studies with comparator group

  • Condition being studied: Central venous line tip position

  • Study population: Participants 18 years or older undergoing Ultrasound-guided central venous line insertion.

  • Intervention: Real-time right supraclavicular fossa ultrasound view

  • Comparator: Chest X-ray or fluoroscopy

  • Outcomes:

    • Incidence of correct CVC tip placement

    • Incidence of CVC malposition detected during intraprocedural right supraclavicular fossa ultrasound

    • Percentage of mispositioned CVC corrected during right supraclavicular fossa ultrasound which was confirmed by chest Xray/Fluoroscopy

    • Any complication during repositioning of mispositioned CVC (Incidence)

  • Sufficient data were available in the study to extract details from the study.

• Exclusion criteria:

  • Studies reporting duplicate data

  • Abstracts, conference proceedings, and reviews

  • Case reports, case series

  • Studies not conducted on humans.

1b. Search results

PubMed Search result

Terms		Search Hits (PubMed)		Combined (PubMed)
Fluoroscopy [MeSH] OR diagnostic X-ray [MeSH] (((diagnostic x ray) OR (radiography)) OR (chest x ray)) OR (fluoroscopy)		2,066,121		#1 AND #2 AND #3 1,492
Central venous catheterizations [MeSH] ((((central venous catheterization) OR (central venous catheter)) OR (central catheter)) OR (central venous catheter tip)) OR (central venous catheter position)		38,588
Interventional ultrasonography [All fields] ((((interventional ultrasound) OR (interventional USG)) OR (ultrasound guided)) OR (USG guided)) OR (Ultrasonography, Interventional)		134,138

Google Scholar and ResearchGate – 1^st 500 articles searched.

(diagnostic x-ray OR “diagnostic x ray” OR radiography OR “chest x-ray” OR “chest x ray” OR fluoroscopy) AND (central venous catheterization OR “central venous catheter” OR “central catheter” OR “central venous catheter tip” OR “central venous catheter position”) AND (interventional ultrasound OR “interventional USG” OR “ultrasound guided” OR “USG guided” OR “Ultrasonography, Interventional”)

SCOPUS – 323 articles obtained.

(TITLE-ABS-KEY (“diagnostic x ray”) OR TITLE-ABS-KEY (“radiography”) OR TITLE-ABS-KEY (“chest x ray”) OR TITLE-ABS-KEY (“fluoroscopy”)) AND (TITLE-ABS-KEY (“central venous catheterization”) OR TITLE-ABS-KEY (“central venous catheter”) OR TITLE-ABS-KEY (“central catheter”) OR TITLE-ABS-KEY (“central venous catheter tip”) OR TITLE-ABS-KEY (“central venous catheter position”)) AND (TITLE-ABS-KEY (“interventional ultrasound”) OR TITLE-ABS-KEY (“interventional USG”) OR TITLE-ABS-KEY (“ultrasound guided”) OR TITLE-ABS-KEY (“USG guided”) OR TITLE-ABS-KEY (“Ultrasonography, Interventional”))