Efficacy and safety of ultrasound-guided infraclavicular axillary vein cannulation for centrally inserted central catheter placement in critically ill patients: systematic review with meta-analysis and trial sequential analysis

Ultrasound (US) guided infraclavicular axillary vein (AXV) central venous catheterization is an emerging method for accessing central veins in critically ill patients. The efficacy and safety of the AXV catheterization remain unknown as compared to more commonly utilized central venous access sites. The main objective was to compare the efficacy and safety of US-guided AXV cannulation with those of other central venous access sites around the upper thoracic aperture region in critically ill patients. We performed a systematic review with meta-analysis. Three databases (PubMed, Web of Science and Scopus) were screened from inception until 1 July 2025 using a predefined search key and inclusion criteria (PROSPERO registration number CRD420251116432). The primary analysis included randomized controlled trials (RCTs) comparing AXV and internal jugular vein (IJV) cannulation. First-pass and overall success rate were evaluated as efficacy outcomes and mechanical complications (separately and cumulatively) as safety outcomes. Two researchers independently screened and extracted data using prespecified criteria. A random-effects inverse variance meta-analysis model was used. Risk of bias and grade of evidence were assessed using the ROB-2 tool and the GRADE approach, respectively. The primary analysis included 908 patients from three RCTs which examined US-guided AXV versus US-guided IJV cannulation. There were no significant differences in overall cannulation success rate (RR = 0.98 (99% CI: 0.95–1.02, p=.16, I2 = 28%)), high certainty) and there was a trend toward lower first pass success rate in the AXV group (RR = 0.93 (99% CI: 0.88-1.00, p=.008, I2 = 0%, high certainty)). This effect was negligible after alternative testing and evaluation of trail sequential analysis (TSA). We found no differences in terms of the cumulative mechanical complication rate (RR = 1.05, 95% CI: 0.69–1.61, p=.81, I2 = 0%, moderate certainty). The TSA revealed the equivalence of AXV to the IJV cannulation in terms of both efficacy and safety. The optimal information size for both aspects was achieved in the TSA. In critically ill patients, US-guided infraclavicular AXV cannulation is equally effective and safe as US-guided IJV cannulation. This systematic review was registered prior its commencement in the PROSPERO database (CRD420251116432).