868927

research-article2019
JVA0010.1177/1129729819868927The Journal of Vascular AccessMaitra et al.

Original research article

JVA The Journal of
Vascular Access

The Journal of Vascular Access

Comparison of long-, short-, and oblique-

1­–6
© The Author(s) 2019
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https://doi.org/10.1177/1129729819868927
DOI: 10.1177/1129729819868927

internal jugular vein cannulation: A journals.sagepub.com/home/jva

network meta-analysis

Souvik Maitra1, Sulagna Bhattacharjee2 and Dalim K Baidya1

Abstract
Background: Comparison between various approaches of ultrasound (USG)-guided internal jugular vein cannulation,
that is, short-axis out-of-plane approach, long-axis in-plane approach, and oblique-axis approach, is sparse. In this network
meta-analysis of randomized controlled trials, all three approaches were evaluated to identify the best technique for
USG-guided internal jugular vein cannulation.
Methods: Randomized controlled trials comparing short-axis out-of-plane approach, long-axis in-plane approach, and
oblique-axis approach in any combination (i.e. comparison of any two or all three) for USG-guided internal jugular vein
cannulation were included in this meta-analysis. Bayesian network meta-analysis was conducted with a non-informative
prior effect size and heterogeneity, and all results were reported as posterior median odds ratio with 95% credible
interval.
Results: Data of 658 patients from five randomized controlled trials were included in this meta-analysis. No difference
was obtained in first attempt success rate of cannulation in three approaches (posterior median odds ratio between long-
axis and short-axis view, oblique-axis and short-axis view, and long-axis and oblique-axis view were 0.67 (0.20, 2.08),
0.92 (0.09, 4.790), and 1.3420 (0.1680, 6.7820), respectively). No difference was seen in the incidence of carotid artery
puncture and overall success rate of cannulation.
Conclusion: All three commonly used approaches for USG-guided internal jugular vein cannulation, that is, short
axis, long axis, and oblique axis, are comparable in terms of clinical utility and safety. There is insufficient evidence to
recommend one approach over another for this purpose.

Keywords
Internal jugular vein, ultrasound, vascular access, central venous access

Date received: 7 May 2019; accepted: 10 July 2019

Internal jugular vein (IJV) cannulation is a frequently used
vascular access both in anesthesiology and critical care
practice. Various mechanical complications such as inad-
vertent carotid artery puncture, thrombosis, hemorrhage,
and hematoma formation were reported from IJV cannula-
tion. Odendaal et al.1 reported that early mechanical com-
plications from IJV cannulation in trauma setting were
around 18%. Although a Cochrane review reported that
use of ultrasound guidance significantly reduced the rate
of inadvertent carotid artery puncture, 26 cases of carotid
artery puncture was reported per 1000 of cannulation
attempt even with the use of USG.2 Carotid artery puncture
is clinically important as it might be associated with stroke
and death.3 Inadvertent carotid artery puncture is still pos-
sible even with real-time USG guidance as the needle tip
and shaft are often not clearly visible in short-axis
1Department of Anaesthesiology, Pain Medicine & Critical Care, All
India Institute of Medical Sciences, New Delhi, New Delhi, India
2Department of Anaesthesia & Critical Care, Institute of Liver & Biliary
Sciences, New Delhi, India
Corresponding author:
Sulagna Bhattacharjee, Department of Anaesthesia & Critical Care,
Institute of Liver & Biliary Sciences, Sector D1, Vasant Kunj, New Delhi
110029, India.
Email: bhattacharjee.sulagna85@gmail.com
2 The Journal of Vascular Access 00(0)
approach. Despite improvement in first attempt cannula-
tion success rate, incidence of inadvertent carotid puncture
may be as high as 4%.4
Most commonly used approaches of USG-guided IJV
cannulation are short-axis out-of-plane and long-axis in-
plane. A recent randomized controlled trial (RCT)
reported that oblique-axis cannulation provided higher
first attempt cannulation success over long-axis in-plane
approach and lower mechanical complications than
short-axis approach.5 Another RCT also reported that
oblique-axis approach improves both needle and guide-
wire visibility during USG-guided IJV cannulation.6 So,
oblique-axis in-plane approach possibly offers advan-
tages of both short- and long-axis approaches.
In this network meta-analysis and systematic review of
RCTs, all three approaches were evaluated to identify the
best technique for USG-guided IJV cannulation.
Methods
We have followed the recommendations of Preferred
Reporting Items for Systematic Reviews and Meta-
Analyses (PRISMA) statement for conducting and report-
ing results of this meta-analysis.7
Eligibility criteria
RCTs comparing short-axis out-of-plane approach, long-
axis in-plane approach, and oblique-axis approach in any
combination (i.e. comparison of any two or all three) for
USG-guided IJV cannulation were included in this meta-
analysis. Studies where USG-guided technique was com-
pared with anatomical landmark-guided technique have
not been included in this meta-analysis. USG-guided can-
nulation technique used in cannulation of any other vessels
was also not included here.
Information sources
PubMed, CENTRAL (Cochrane Central Register of
Controlled Trials), and EMBASE were searched for poten-
tially eligible trials from inception to April 30, 2019. No
language restriction was applied in the search strategy.
References of the previously published meta-analyses and
randomized trials were also searched manually to identify
eligible trials.
Search strategy
Following keywords were used to search database: “IJV
cannulation, internal jugular vein cannulation, short axis
approach, long axis approach, medial oblique approach,
oblique approach, ultrasound IJV cannulation, USG IJV
cannulation.”
Study selection
Title and abstract of the potentially eligible trials were
searched by S.M. and D.K.B. independently. Potentially
eligible articles were assessed from full text for inclusion.
Any disputes between the two authors were planned to be
solved by discussion with the third author (S.B.).
Data collection process
All required data from the eligible trials were tabulated
in a Microsoft Excel™ (Microsoft Corp., Redmond,
WA) data sheet independently by two authors (S.M. &
S.B.). All data were cross-checked by the third authors
(D.K.B.).
Data items
Following data were extracted from the full text for all
studies: Name of the first author, year of publication, sam-
ple size, characteristics of included patients, approach to
IJV cannulation, first attempt cannulation success, cannu-
lation success rate, cannulation time, and any reported
complications.
Risk of bias in individual studies
Two authors (S.M. & D.K.B.) independently assessed the
methodological quality of the included studies as per
Cochrane methodology.8 Risk of bias at individual study
level is graphically presented in the review.
Summary measures and synthesis of results
Primary outcome of this meta-analysis is “first attempt
cannulation success rate” in the included patients.
Secondary outcomes are incidence of carotid artery punc-
ture, overall cannulation success rate, and time to
cannulation.
Binary outcomes were reported in odds ratio with 95%
credible interval (95% CrI). For continuous variables such
as time to cannulation, mean and standard deviation (SD)
values were extracted for both group of patients, a mean
difference was computed at the study level, and mean dif-
ference was computed in order to pool the results across all
studies. If the values were reported as median and an inter-
quartile range or total range of values, the mean value was
estimated by a previously described method.9 Bayesian
network meta-analysis by arm-based approach was con-
ducted by “pcnetmeta” package in R (R Foundation for
Statistical Computing, Vienna, Austria).10 Only a non-
informative prior effect size and heterogeneity were used
for all analysis. All results were reported as posterior
median odds ratio with 95% CrI.
Maitra et al. 3

Results
Five hundred forty-five articles were identified from
searching of the databases and other sources. After
duplicate removal, 39 articles were assessed from
abstract and full texts. A flow diagram showing sequence
of database searching and study selection has been pro-
vided in Figure 1. Finally, data of 658 patients from five
RCTs were included in this meta-analysis.5,6,11–13 Among
them, three RCTs compared short-axis view with long-
axis view,11–13 one compared oblique-axis view with
short-axis view,6 and another one compared all three
views.5 Characteristics of the individual studies have
been provided in Table 1. Summary of risk of biases has
been provided in Figure 2.
All the included trials reported rate of first attempt can-
nulation success and posterior median odds ratio (95%
CrI) between long-axis and short-axis view, oblique-axis
and short-axis view, long-axis and oblique-axis view were
0.67 (0.20, 2.08), 0.92 (0.09, 4.790), and 1.3420 (0.1680,
6.7820), respectively (Figure 3). Rank probability test
revealed that probability of being the best approach was
0.47 for short-axis view, 0.41 for oblique-axis view, and
0.11 for long-axis view (Deviance Information Criterion
(DIC) 59.15). No difference was seen in overall cannula-
tion success rate between all three approaches.
Rate of carotid artery puncture was also similar in all
three approaches. Posterior median OR (95% CrI) was
1.75 (0.1, 36.6) for long-axis versus short-axis approach,
0.89 (0.01, 39.4) for oblique-axis versus short–axis, and
0.49 (0.01, 20.58) for oblique-axis approach versus long-
axis approach (Figure 4). Rate of posterior IJV wall punc-
ture was reported only in two RCTs, and long-axis
Figure 1. Prisma flow diagram for database searching and
approach is associated with least probability of posterior
study selection.

Table 1. Characteristics of the included trials.

Author Participants Intervention Control Primary outcome

Batllori et al.5 Adult patients requiring IJV Oblique-axis approach Short-axis out-of- First needle pass
cannulation (n = 220) (cranio-lateral) plane approach cannulation success
Long-axis in-plane approach
Baidya et al.6 Adult patients undergoing any Oblique-axis approach Short-axis out-of- Needle
surgery under general anesthesia (cranio-medial) plane approach visualization during
requiring IJV cannulation cannulation
(n = 200)
Chittoodan et al.13 Adult patients undergoing cardiac Long-axis in-plane approach Short-axis out-of- First attempt
surgery (n = 99) plane approach success rate
Shrestha et al.11 Adult patients requiring IJV Long-axis in-plane approach Short-axis out-of- First attempt
cannulation in OR/ICU (n = 82) plane approach success rate
Tammam et al.12a Adult patients requiring IJV Long-axis in-plane approach Short-axis out-of- Success rate of
cannulation in ICU/hemodialysis plane approach cannulation
unit (n = 60)

IJV: internal jugular vein, ICU: intensive care unit, OR: operating room.
aThis study had another arm of landmark-based IJV cannulation, which was not included in this meta-analysis.
4 The Journal of Vascular Access 00(0)
Figure 2. Risk of biases in the individual studies (red: high risk
of bias, green: no risk of bias, and yellow: unclear risk of bias).
Figure 3. Absolute plot showing posterior median risk (upper left), contrast plot showing posterior median odds ratio (95%
credible interval) of first attempt cannulation success rate (upper right), and rank probability plot showing probability of best
approach in terms of first attempt cannulation success.
IJV wall puncture. We have not analyzed time to cannula-
tion as it was defined differently across the studies.
Discussion
Principal findings of this meta-analysis are that none of the
described approach of USG-guided IJV cannulation, that
is, short axis, long axis, and oblique axis, is superior to any
one of them in terms of first attempt cannulation success
rate, incidence of carotid artery puncture, and puncture of
the posterior wall of IJV.
Ultrasonography provides “real time” imaging, that is,
the needle can be visualized entering the vein, thus reducing
the incidence of complications and increasing the success
rate. Traditional approaches of IJV cannulation, such as
short-axis out-of-plane and long-axis in-plane, have several
disadvantages. Short-axis approach allows to visualize IJV
and carotid artery as distinct structure, but the puncture nee-
dle is often seen as a “dot” and both the tip and shaft of the
needle are difficult to visualize. Lack of needle tip visibility
increases the possibility of inadvertent carotid artery punc-
ture and puncture of the posterior wall of IJV. Possibility of
carotid artery puncture increases particularly when there is a
significant overlap between these two vessels. On the con-
trary, though long-axis in-plane approach allows visualiza-
tion of the whole needle, carotid artery is not visualized
along with the IJV. Currently, long-axis approach is recom-
mended for USG-guided vascular access as the tip of the
puncture needle can be controlled more precisely.5
Maitra et al.
Figure 4. Absolute plot showing posterior median risk (left) and contrast plot showing posterior median odds ratio (95% credible
interval) of carotid artery puncture rate (right).
Dilisio and Mittnacht14 in 2012 suggested that in medial
oblique probe position, benefit of both short axis and long
axis could be obtained. They also mentioned that in this
view, needle entry path could be followed from skin to the
vessel. In 2018, Baidya et al.6 reported that needle visibil-
ity and guidewire visibility both enhanced in medial
oblique view when compared with short-axis view. In
oblique view, the whole of puncture needle along its entry
path is visualized, so both the tip and shaft of the needle
are seen. Moreover, in oblique view, the ultrasound beam
is transmitted through an oblique axis over the IJV. So, a
longer length of IJV is being scanned in oblique axis,
which will increase effective transverse diameter and
reduce the overlapping between IJV and carotid artery.15
Overlapping between IJV and carotid artery is common in
USG, and classic anatomy of IJV being lateral to the
carotid artery is seen only in 10% of the patients.15,16
Strength and limitations
Most important strength of this meta-analysis is the use of
Bayesian network approach for multiple arm comparison.
We have included all three approaches of USG-guided IJV
cannulation in this meta-analysis.
This meta-analysis only included five RCTs and among
them only two RCTs used medial oblique approach.
Second, sample size of the included studies is small, and
they are prone to several biases. Third, most important
clinical outcome of this meta-analysis is “carotid artery
puncture,” which is a rare outcome; hence, meaningful
analysis is difficult. Fourth, orientation of the oblique axis
(i.e. medio-lateral or latero-medial) can also determine
the success of this approach. Fifth, experience of the oper-
ator performing IJV cannulation also determines the suc-
cess of the procedure, and an ideal technique should be
safe and useful even when used by relatively inexperi-
enced operators. It is also impossible to determine the best
approach in difficult cases such as in patients with small
collapsible IJV.
Conclusion
All three commonly used approaches for USG-guided IJV
cannulation, that is, short axis, long axis, and oblique axis,
5
are comparable in terms of clinical utility and safety. There
is insufficient evidence to recommend one approach over
another for this purpose.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Ethical statement
Permission from the Institute Ethics Committee is not required as
it is a meta-analysis.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
ORCID iD
Sulagna Bhattacharjee https://orcid.org/0000-0001-8671-6875
References
1. Odendaal J, Kong VY, Sartorius B, et al. Mechanical compli-
cations of central venous catheterisation in trauma patients.
Ann R Coll Surg Engl 2017; 99(5): 390–393.
2. Bowdle TA. Central line complications from the ASA
closed claims project: an update. ASA News Lett 2002; 66:
1125–1112.
3. Brass P, Hellmich M, Kolodziej L, et al. Ultrasound guid-
ance versus anatomical landmarks for internal jugular vein
catheterization. Cochrane Database Syst Rev 2015; 1:
CD006962.
4. Augoustides JG, Horak J, Ochroch AE, et al. A randomized
controlled clinical trial of real-time needle guided ultra-
sound for internal jugular venous cannulation in a large uni-
versity anesthesia department. J Cardiothorac Vasc Anesth
2005; 19(3): 310–315.
5. Batllori M, Urra M, Uriarte E, et al. Randomized compari-
son of three transducer orientation approaches for ultra-
sound guided internal jugular venous cannulation. Br J
Anaesth 2016; 116(3): 370–376.
6. Baidya DK, Arora MK, Ray BR, et al. Comparison between
classic short-axis out-of-plane approach and novel medial-
oblique in-plane approach to ultrasound guided right inter-
nal jugular vein cannulation: a randomized controlled trial.
Acta Anaesth Belg 2018; 69: 107–112.
6 The Journal of Vascular Access 00(0)
7. Moher D, Liberati A, Tetzlaff J, et al; PRISMA Group.
Preferred reporting items for systematic reviews and meta-
analyses: the PRISMA statement. PLoS Med 2009; 6:
e1000097.
8. Higgins JPT, Altman DG and Sterne JAC. Assessing risk
of bias in included studies. In: Higgins JPT and Green
S (eds) Cochrane handbook for systematic reviews
of interventions version 5.1.0 (updated March 2011).
The Cochrane Collaboration, 2011, www.handbook.
cochrane.org
9. Hozo SP, Djulbegovic B and Hozo I. Estimating the mean
and variance from the median, range, and the size of a sam-
ple. BMC Med Res Methodol 2005; 5: 13.
10. Lin L, Zhang J, Hodges JS, et al. Performing arm-based net-
work meta-analysis in R with the pcnetmeta package. J Stat
Softw 2017;80: 5.
11. Shrestha GS, Gurung A and Koirala S. Comparison between
long- and short-axis techniques for ultrasound-guided can-
nulation of internal jugular vein. Ann Card Anaesth 2016;
19(2): 288–292.
12. Tammam TF, El-Shafey EM and Tammam HF. Ultrasound-
guided internal jugular vein access: comparison between
short axis and long axis techniques. Saudi J Kidney Dis
Transpl 2013; 24(4): 707–713.
13. Chittoodan S, Breen D, O’Donnell BD, et al. Long versus
short axis ultrasound guided approach for internal jugular
vein cannulation: a prospective randomised controlled trial.
Med Ultrason 2011; 13(1): 21–25.
14. Dilisio R and Mittnacht AJ. The “medial-oblique” approach
to ultrasound-guided central venous cannulation–maximize
the view, minimize the risk. J Cardiothorac Vasc Anesth
2012; 26(6): 982–984.
15. Baidya DK, Chandralekha, Darlong V, et al. Comparative
sonoanatomy of classic “short axis” probe position with
a novel “medial-oblique” probe position for ultrasound-
guided internal jugular vein cannulation: a crossover study.
J Emerg Med 2015; 48(5): 590–596.
16. Troianos CA, Kuwik RJ, Pasqual JR, et al. Internal jugular
vein and carotid artery anatomic relation as determined by
ultrasonography. Anesthesiology 1996; 85(1): 43–48.