Original Investigation

Use of Real-Time Ultrasound Guidance for the Placement of

Hemodialysis Catheters: A Systematic Review and Meta-analysis
of Randomized Controlled Trials
Kannaiyan Samuel Rabindranath, MRCP, PhD,1 Emil Kumar, MBChB,2
Ranjit Shail, MRCP,3 and Emma Vaux, FRCP, PhD4
Background: Insertion of percutaneous hemodialysis catheters is an invasive procedure with a small but
definite risk of morbidity and mortality.
Objectives: Assessing potential benefits of using real-time 2-dimensional Doppler ultrasound imaging
guidance for the insertion of hemodialysis catheters compared with insertion based solely on anatomic
landmarks.
Study Design: Systematic review and meta-analysis of randomized controlled trials.
Data Sources: MEDLINE (1966 to July 2010), EMBASE (1980 to July 2010), Cochrane Renal Group
Specialised Register, and Cochrane Central Register of Controlled Trials (CENTRAL).
Setting & Population: Patients requiring hemodialysis catheter insertion.
Selection Criteria for Studies: We included all randomized controlled trials regardless of publication status
or language.
Interventions: Real-time 2-dimensional Doppler ultrasound image guidance.
Outcomes: Catheter placement failures, catheters failed to be placed in the first attempt, attempts per
catheter inserted, time taken for successful venous puncture, and complications (carotid artery puncture,
pneumo- or hemothorax, neck hematoma, and brachial plexus injury). Treatment effects were summarized
with the RR measure for dichotomous outcomes and mean difference for continuous outcomes.
Results: 7 trials with 830 catheters were identified. Ultrasound guidance significantly decreased the risk of
the following outcomes: catheter placement failure (7 studies, 830 catheters; RR, 0.12; 95% CI, 0.04-0.37),
failure to place catheter on first attempt (5 studies, 595 catheters; RR, 0.40; 95% CI, 0.29-0.56), arterial
punctures (6 trials, 785 catheters; RR, 0.22; 95% CI, 0.06-0.81), and hematoma formation (4 trials, 323
catheters; RR, 0.27; 95% CI, 0.08-0.88). It also significantly decreased the time to cannulate the vein (1 trial, 73
catheters; mean difference, 1.40; 95% CI, 2.17 to 0.63), and number of attempts per catheter insertion (1
trial, 110 catheters; mean difference, 0.35; 95% CI, 0.54 to 0.16).
Limitations: Only 7 studies were identified, of which 3 were reported in only a conference abstract form.
Some outcomes were reported in only 1 study.
Conclusions: Use of real-time Doppler ultrasound guidance has benefits with respect to several
important clinical outcomes, and its routine use in the insertion of hemodialysis catheters is strongly
recommended.
Am J Kidney Dis. 58(6):964-970. 2011 by the National Kidney Foundation, Inc.
INDEX WORDS: Hemodialysis; hemodialysis catheters; ultrasound; systematic review.

ascular access for hemodialysis is best achieved

through an arteriovenous fistula, which is
considered the reference standard. However, an
increasing number of patients are starting dialysis
therapy with either temporary catheters or tunneled
cuffed catheters.1 Insertion of these percutaneous
catheters is an invasive procedure with a small but
definite risk of morbidity and mortality. Reasons

for this include anatomic variation of the vascular

structures and a thick neck in obese individuals.
Central venous cannulation for the placement of
hemodialysis catheters generally is performed using the Seldinger technique by either identifying
the veins using traditional anatomic landmarks
(landmark method) or visualizing the veins using
real-time 2-dimensional ultrasound scan guidance.

From the 1Renal Unit, New Cross Hospital, Wolverhampton;

Department of Medicine, St. Marys Hospital, London; 3Acute
Admissions Unit, Hastings General Hospital, Hastings; and 4Renal Unit, Royal Berkshire Hospital, Reading, United Kingdom.
Received December 17, 2010. Accepted in revised form July 27,
2011.
This review is excerpted from a Cochrane Review published in
The Cochrane Library 2011, Issue 10 (http://onlinelibrary.wiley.
com/doi/10.1002/14651858.CD005279.pub4/full). All Cochrane

Reviews are regularly updated as new evidence emerges in response to comments and criticisms, and the reader is directed to
The Cochrane Library for updated information on this topic.
Address correspondence to Kannaiyan Samuel Rabindranath,
MRCP, PhD, Renal Unit, New Cross Hospital, Wolverhampton
WV10 0QP, UK. E-mail: ksrabi@yahoo.co.uk
2011 by the National Kidney Foundation, Inc.
0272-6386/$36.00
doi:10.1053/j.ajkd.2011.07.025

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Am J Kidney Dis. 2011;58(6):964-970

Ultrasound for the Placement of Hemodialysis Catheters

The use of landmark techniques for puncture of the

central veins may result in significant immediate
complications. Arterial puncture, hematoma formation, pneumothorax, and hemothorax are the commonly reported complications.2 Therefore, ultrasound
guidance has become increasingly popular in an endeavor to minimize complications of central venous
catheter (CVC) insertion. It provides real-time gray
scale imaging of the anatomy. Portable ultrasound
machines are convenient and can be used at the
bedside, radiology suites, theaters, and high-care or
intensive care settings.
Data from the insertion of CVCs in the nondialysis
population using insertion based solely on the anatomic landmark technique showed cannulation failure
rates of 7%-19.4% and perioperative complications of
0.2%-35.4%.3 Use of ultrasound guidance has been
shown to reduce catheterization-related morbidity
compared with insertion based solely on the anatomic
landmark technique (first-pass cannulation, 91% vs
38%; carotid artery puncture, 1.7% vs 38%).4 The UK
National Institute for Clinical Excellence (NICE) and
the Renal Association (UK) both recommend the use
of 2-dimensional ultrasound imaging for central venous catheterization.5,6 The risk for placement of
hemodialysis catheters in the dialysis population may
be higher because these catheters are much larger in
caliber compared with normal central venous cannulas and uremia adversely affects the clotting ability of
blood, thereby increasing the risk of bleeding. This
review assesses the potential advantages of the use of
ultrasound imaging for the insertion of hemodialysis
catheters compared with insertion based solely on
anatomic landmarks.

METHODS
Protocol and Registration
The protocol of this review was registered with the Cochrane
Renal Group.7

Inclusion Criteria and Outcomes

We included all randomized controlled trials (RCTs) without
language restriction that compared the landmark method (ie, use of
anatomic landmarks alone) with the use of 2-dimensional ultrasound venous imaging (ultrasound guidance) in the insertion of
percutaneous CVCs for hemodialysis. For the purpose of this
review, real-time 2-dimensional ultrasound venous imaging subsequently is referred to as ultrasound guidance. All patients requiring
insertion of a hemodialysis catheter (tunneled or nontunneled)
were considered eligible for inclusion.
The outcomes assessed were number of failed catheter placements (inability to site the catheter at the initial preferred site using
the original technique), number of failed catheter placements on
the first attempt, time per cannulation, number of cannulation
attempts per catheter placement, complications (arterial punctures,
hematomas, pneumo- or hemothorax, and brachial plexus injury).

Search Strategy
Using sensitive Cochrane search methodology, searches were
performed in MEDLINE (1950 through July 2010), EMBASE
(1980 through July 2010), and Cochrane Central Register of
Controlled Trials (CENTRAL; through July 2010). The Cochrane
Renal Group Specialised Register also was searched. The following medical subject heading terms and text words were used:
ultrasound, hemodialysis, and central venous catheters. Trials were
considered without language restriction.

Data Extraction and Quality Assessment

We followed Cochrane methods and Quality of Reporting of
Meta-analyses (QUOROM) guidelines for conduct and reporting
of this systematic review.8 Two of 4 authors (K.S.R and R.S)
independently assessed studies for eligibility and extracted data for
study characteristics, such as sample size, hemodialysis catheter

Figure 1. Flow chart illustrates the process of literature searching up to the

identification of trials to be
included in the systematic
review. Reasons for exclusion are provided.
Am J Kidney Dis. 2011;58(6):964-970

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966

Table 1. Study Characteristics

Study

Time Period

Publication
Status

No. of
Patients

No. of
Catheters

Mean
Age (y)

Patients With Previous

Catheters (%)

60

60

40.95

13.3

Internal jugular

185

212

67.05

NR

80

80

67.50

242

250

NR

Bansal et al,10 2005

March-June 2004

Peer-reviewed

Ibrik Ibrik et al,11

2000

March 1996-December
1999

Conference
abstract

Koroglu,12 2006

July 1996-March 1997

Peer-reviewed

Kumwenda,13 2003

1997-2001

Conference
abstract

Clinical
Setting

Definition of Failed Catheter

Placement

Nontunneled

ESKD

3 attempts or inability to cannulate

the vein

66% internal jugular, 5%

femoral, 29% subclavian

85% Nontunneled, 15% tunneled

NR

NR, but all cannulas successfully

placed and no. of attempts
explicitly stated

NR

Internal jugular

Overall, 60% nontunneled, 40%

tunneled; however,
nontunneled catheters were
used in 97% of landmark
method group and only 22.5%
of ultrasound method group

AKI

Not defined

NR

Internal jugular

Tunneled

ESKD

Not defined, but all catheters appear

to have been successfully placed

Site of Insertion

Type of Catheter

Nadig et al,14 1998

NR

Peer-reviewed

65

73

59.50

NR

Internal jugular

NR

NR

Not defined explicitly

Prabhu et al,15 2010

April-November 2008

Peer-reviewed

110

110

48.90

NR

Femoral

Nontunneled

NR

Placement of catheter not

accomplished after 3 attempts at
venous cannulation

Zafar-Khan et al,16
1995

NR

Conference
abstract

45

45

NR

NR

Internal jugular

NR

NR

Not defined

Abbreviations: AKI, acute kidney injury; ESKD, end-stage kidney disease; NR, not reported.

Table 2. Risk of Bias Assessment

Study

Adequate Sequence
Generation

Insertion Based Solely on Anatomic

Landmarking

Intention-to-Treat
Analysis

Incomplete Outcome
Data Addressed

Free of Selective
Reporting

Free From
Other Bias

Considered not possible due to nature

of intervention
Considered not possible due to nature
of intervention
Considered not possible due to nature
of intervention
Considered not possible due to nature
of intervention
Considered not possible due to nature
of intervention
Considered not possible due to nature
of intervention
Considered not possible due to nature
of intervention

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Bansal et al,10 2005

Unclear

Adequate

Ibrik Ibrik et al,11 2000

Unclear

Unclear

Koroglu et al,12 2006

Adequate

Unclear

Kumwenda,13 2003

Adequate

Adequate

Nadig et al,14 1998

Adequate

Unclear

Prabhu et al,15 2010

Adequate

Unclear

Zafar Khan et al,16 1995

Unclear

Unclear

Rabindranath et al

Am J Kidney Dis. 2011;58(6):964-970

Allocation
Concealment

Ultrasound for the Placement of Hemodialysis Catheters

types (nontunneled or tunneled), site of venous cannulation (internal jugular, subclavian, or femoral), methodological characteristics
of the trials, and outcomes. Quality of the trials was assessed using
standard criteria (allocation concealment, insertion based solely on
anatomic landmarks, analysis by intention to treat, and completeness of follow-up).9 Discrepancies between the 2 data extractors
(K.S.R and R.S.) were resolved by discussion with an arbitrator
(E.V).

Statistical Analysis
Treatment effects were summarized with the relative risk (RR)
measure and its 95% confidence interval (CI) for dichotomous
outcomes and the mean difference and its 95% CI for continuous
outcomes. Estimates from individual RCTs were pooled using the
Mantel-Haenszel random-effects model. Heterogeneity of treatment effects between studies was formally tested using the Q
(heterogeneity 2) and I2 statistics. Analyses were performed using
Review Manager (RevMan, version 5.0; The Cochrane Collaboration, http://ims.cochrane.org/revman).

RESULTS
Search Yield
The search of electronic databases mentioned
identified 2,613 articles, of which 2,598 were excluded. Major reasons for exclusion were that selected studies were duplicate-citation nonrandomized studies or randomized trials with comparisons
or outcomes that were not relevant to this review
(Fig 1). Full-text assessment of 15 potentially eligible articles identified 7 eligible trials (830 catheters).10-16 Three trials were published in only
conference abstract form.11,13,16
Real-time USS guidance Landmark method
Study or Subgroup
Events
Total Weight
Total
Events
1.1.1 Studies published in peer-reviewed publications
Prabhu 2010
Nadig 1998
Korogolu 2006
Bansal 2005
Subtotal (95% CI)

1
0
0
0

55
36
40
30
161

11
13
1
2

Trial Characteristics
Table 1 lists the characteristics of the 7 RCTs
included in this review. Not all outcomes were analyzed or reported by each individual trial.
Risk of Bias
Risk of bias in the included trials is listed in Table
2. Sequence generation was adequate in 71% of
studies. Allocation concealment was unclear in 57%
and adequate in 43% of studies. Because of the nature
of the investigation, we did not expect insertion based
solely on anatomic landmarking of participants and
investigators. None of the studies reported insertion
based solely on anatomic landmarking of outcome
assessors. All studies analyzed results on an intentionto-treat basis. None of the included patients was lost
to follow-up.
Outcomes
Risk of Catheter Placement Failure
Ultrasound guidance was found to reduce the risk
of catheter placement failure significantly compared
with the landmark method (7 studies, 830 catheters;
RR, 0.12; 95% CI, 0.04-0.37; Fig 2). There was no
significant heterogeneity between studies (2 1.79;
P 0.88; I2 0%).
Risk of Failure of Catheter Placement on First Attempt

Ultrasound guidance was found to reduce the risk

of this outcome significantly compared with the landRisk Ratio
M-H, Random, 95% CI

55
37
40
30
162

30.6%
16.0%
12.3%
13.8%
72.7%

0.09 [0.01, 0.68]

0.04 [0.00, 0.62]
0.33 [0.01, 7.95]
0.20 [0.01, 4.00]
0.11 [0.03, 0.40]

20
125
73
218

15.1%
12.2%
27.3%

0.09 [0.01, 1.57]

0.33 [0.01, 8.10]
Not estimable
0.16 [0.02, 1.36]

380 100.0%

0.12 [0.04, 0.37]

Risk Ratio
M-H, Random, 95% CI

27
Total events
1
Heterogeneity: Tau = 0.00; Chi = 1.31, df = 3 (P = 0.73); I = 0%
Test for overall effect: Z = 3.33 (P = 0.0009)
1.1.2 Studies published only as conference abstracts
Zafar-Khan 1995
Kumwenda 2003
Ibrik 2000
Subtotal (95% CI)

0
0
0

25
125
139
289

4
1
0

Total events
5
0
Heterogeneity: Tau = 0.00; Chi = 0.37, df = 1 (P = 0.54); I = 0%
Test for overall effect: Z = 1.68 (P = 0.09)
Total (95% CI)

450

Total events
32
1
Heterogeneity: Tau = 0.00; Chi = 1.79, df = 5 (P = 0.88); I = 0%
Test for overall effect: Z = 3.72 (P = 0.0002)

0.001
1000
0.1
1
10
Favours US guidance Favours Landmark method

Figure 2. Risk of catheter placement failure. Abbreviations: CI, confidence interval; M-H, Mantel-Haenszel; US, ultrasound; USS,
ultrasound scan.
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Rabindranath et al
Table 3. Data for Attempts per Catheter Placement
Real-Time Ultrasound Guidance

Landmark Method

No. of
Catheters

No. of Attempts per

Catheter Placement

No. of
Catheters

No. of Attempts per

Catheter Placement

Koroglu et al,13 2006

40

1.10

40

2.47

Nadig et al,14 1998

36
25

1.11
1.50

37
20

2.70
3.50

Study

Zafar-Khane et al,16
1995

mark method (5 studies, 595 catheters; RR, 0.40; 95%

CI, 0.29-0.56). There was no significant heterogeneity
between studies (2 3.79; P 0.29; I2 21%).
Number of Attempts per Catheter Insertion

Only 1 study reported this outcome in a metaanalyzable format.15 According to data from this
study, ultrasound guidance was associated with a
significantly smaller number of attempts per catheter
placement (1 trial, 110 catheters; mean difference,
0.35; 95% CI, 0.54 to 0.16). See Table 3 for
data from other studies that have reported this outcome.12,14,16
Time Taken for Venous Cannulation

Ultrasound guidance was associated with significantly less time (minutes from skin anesthesia to
successful vein puncture) for successful vein puncture
from the time the skin was anaesthetized (1 trial, 73
catheters; mean difference, 1.40; 95% CI, 2.17 to
0.63).

associated with a higher number of arterial punctures

compared with the control group (4 of 125 vs 3 of 125
catheter placements). We were not able to find a
specific reason for the slightly increased incidence of
arterial puncture with ultrasound guidance in this
study.
Hematoma Ultrasound guidance was associated
with a significantly decreased risk of hematoma (4
trials, 323 catheters; RR, 0.27; 95% CI, 0.08-0.88).
Heterogeneity measures were not significant (2
1.12; P 0.57; I2 0%).
Pneumo- or hemothorax There was no difference between patient groups in the risk of pneumo- or hemothorax (5 trials, 675 catheters; RR, 0.23; 95% CI,
0.04-1.37). Heterogeneity measures were not significant (2 0.08; P 0.96; I2 0%).
Other None of the studies assessed the number of
catheter insertions associated with central vein perforation or brachial plexus injury.

DISCUSSION

Complications

Ultrasound guidance was associated with a significantly reduced risk of carotid artery
puncture (6 trials, 785 catheters; RR, 0.22; 95% CI,
0.06 to 0.81; Fig 3). Heterogeneity measures were
moderately significant (2 7.99; P 0.09; I2
50%). The Kumwenda13 2003 study contributed to
heterogeneity because it was the only study in which
catheters inserted using ultrasound guidance were
Arterial puncture

Study or Subgroup
Bansal 2005
Ibrik 2000
Korogolu 2006
Kumwenda 2003
Nadig 1998
Prabhu 2010
Total (95% CI)

Real-time USS guidance Landmark method

Events
Total
Events
Total Weight
0
2
0
4
0
1

30
139
40
125
36
55

4
6
14
3
0
6

425

Total events
7
33
Heterogeneity: Tau = 1.04; Chi = 7.99, df = 4 (P = 0.09); I = 50%
Test for overall effect: Z = 2.28 (P = 0.02)

We identified 7 trials with 830 catheter placements.

This systematic review found the use of real-time
ultrasound guidance compared with the landmark
method in the placement of hemodialysis catheters to
have a number of clinically important benefits by
significantly reducing: (1) the risk of failure of catheter placements and failure of placing catheters on the
first attempt, (2) the time needed for successful vein
Risk Ratio
M-H, Random, 95% CI

19.9%

0.11 [0.01, 1.98]

0.18 [0.04, 0.85]
0.03 [0.00, 0.56]
1.33 [0.30, 5.84]
Not estimable
0.17 [0.02, 1.34]

360 100.0%

0.22 [0.06, 0.81]

30
73
40
125
37
55

13.5%
25.6%
14.1%
26.9%

Risk Ratio
M-H, Random, 95% CI

0.1
1
10
0.002
500
Favours USS guidance Favours Landmark method

Figure 3. Risk of arterial puncture. Abbreviations: CI, confidence interval; M-H, Mantel-Haenszel; USS, ultrasound scan.
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Ultrasound for the Placement of Hemodialysis Catheters

Table 4. Recommendations of Various Guidelines Regarding Hemodialysis Catheter Placement
Guideline

Kidney Disease Outcomes Quality

Initiative (KDOQI)18
Caring for Australasians with
Renal Impairment (CARI)19
Renal Association (UK)6

Country

Year

Recommendation

USA

2006

Ultrasound should be used for catheter placement

Australia

2000

UK

2011

Catheters should be placed under direct vision,

either surgical or ultrasound guidance
Real-time ultrasound guidance should be used to
aid access placement in upper-body and
femoral veins

puncture, and (3) the risk of arterial punctures and

hematoma formation.
Several studies previously have shown the advantages of ultrasound guidance in central venous cannula placements; in other words, in nonhemodialysis
settings.4 The literature search done to inform the
NICE report on the use of ultrasound for CVC placements identified 20 RCTs (6 using audio Doppler, 13
using 2-dimensional Doppler, and 1 using both) comparing ultrasound versus traditional landmark methods for CVC insertion.5 This review found that use of
ultrasound techniques significantly decreased the risks
of failed catheter placements (9 trials; RR, 0.16; 95%
CI, 0.09-0.90), failure of catheter insertion at the first
attempt (4 trials; RR, 0.59; 95% CI, 0.39-0.88), and
any complications (7 trials; RR, 0.36; 95% CI, 0.170.76). These findings are similar to results from this
systematic review.
Although evidence for the use of ultrasound guidance for CVC insertion was evaluated thoroughly in
the NICE 2002 report, no such review of evidence had
been conducted to date for the use of ultrasound in the
setting of hemodialysis catheter insertion.5 The
strength of this analysis is that it is a comprehensive
systematic review of RCTs assessing the efficacy of
the use of real-time ultrasound guidance for the insertion of hemodialysis catheters. We used rigid inclusion criteria in considering RCTs only and performed
a very comprehensive search strategy of all major
medical electronic databases and other sources.
The major limitation of this review has been the
small number of trials identified and the fact that these
7 trials put together had a total of only 830 catheter
insertions. It is equally important to note that 3 studies
were reported in only abstract form.11,13,16 These 3
studies together account for more than half the catheters included in the meta-analysis (507 of 830). It
therefore was difficult to obtain details for patient
characteristics and study quality from these studies.
Not all outcomes were reported in all studies and
some outcomes were reported in only 1 study. Patient
characteristics with regard to clinical setting (endstage kidney disease or acute kidney injury) were not
available for 4 of the included studies.11,14,15,16 We
Am J Kidney Dis. 2011;58(6):964-970

therefore were unable to perform subgroup analysis

based on this important clinical characteristic. Again,
information for operator experience was not available
for all studies. Despite this, as described here, metaanalysis of these studies highlights several striking
advantages for real-time ultrasound guidance.
Subclavian catheters were included in 1 study and
made up only about a third of the catheters placed in
that study.11 It was not possible to analyze data for
vein sites separately because the study that included
all 3 venous sites was published in only abstract form
and we were not able to obtain data for the different
venous sites separately. Evidence for ultrasound guidance in the placement of subclavian catheters therefore is limited. The lack of benefit of ultrasound
guidance with respect to the outcomes of pneumoand hemothorax is not surprising. These complications are rare with CVC placements, so much so that
some studies believe that routine chest radiographs
after catheter placement are not routinely warranted.17
It therefore is very likely that a significant difference
between catheter insertion methods was not discerned
due to lack of sufficient patient numbers in the studies
to pick out such a rare outcome.
NICE and various renal societies also recommend
the use of ultrasound guidance for the placement of
CVCs, as listed in Table 4.5,6,18,19 The findings from
our systematic review provide high-quality evidence
to support these recommendations.

ACKNOWLEDGEMENTS
We thank the staff of the Cochrane Renal Group (Narelle Willis
and Gail Higgins) for assistance with the review and Drs Bansal,
Kumwenda, and Prabhu for responding to our requests for further
information about their studies.
Support: None.
Financial Disclosure: The authors declare that they have no
relevant financial interests.

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