Comparative Outcomes of Central Venous Access via Open Jugular and Ultrasound-Guided Subclavian Approaches in Low-Weight Pediatric Patients: A Study with Secondary Outcomes

Comparative Outcomes of Central Venous Access via Open Jugular and Ultrasound-Guided Subclavian Approaches in Low-Weight Pediatric Patients: A Study with Secondary Outcomes | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Comparative Outcomes of Central Venous Access via Open Jugular and Ultrasound-Guided Subclavian Approaches in Low-Weight Pediatric Patients: A Study with Secondary Outcomes Ebrahim Farhadi, Mohsen Rezaee, Saeed Aslanabadi, Davoud Badebarin, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7933826/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Background The necessity of this study stems from the lack of comparative evidence on the outcomes of central venous catheterization via the open internal jugular and ultrasound-guided subclavian approaches in low-weight pediatric patients. Its innovation lies in the simultaneous evaluation of both primary and secondary outcomes of these two techniques in this vulnerable population. Methods This prospective randomized clinical trial at Mardani Azar Children’s Hospital (winter 2022–2023) included 92 pediatric patients under five kilograms weight, randomly assigned to either open internal jugular or ultrasound-guided subclavian vein catheterization (46 per group). Procedural success and major complications—such as pneumothorax, arterial cannulation, ectopic catheter placement, infection, and thrombosis—were evaluated intraoperatively and during a two-weeks follow-up using imaging and clinical assessment. Results The mean catheter placement time was significantly longer in the jugular group than in the subclavian group (41.19 ± 13.8 vs. 33.15 ± 12.12 minutes; P = 0.04). No cases of pneumothorax, hemothorax, bleeding, arrhythmia, occlusion, infection, or death occurred in either group (P = 1). Hematoma developed only in the jugular group (6 vs. 0; P = 0.02), and all cases were associated with a procedure duration greater than 35 minutes (P = 0.041). In the subclavian group, all failures (n = 4) and upper limb edema (n = 3) occurred exclusively in patients under 2.5 kg, with both outcomes significantly linked to lower body weight (P = 0.03 and P = 0.014, respectively). Other complications showed no significant differences between groups. Conclusion Based on the findings from this study comparing two central venous catheterization techniques in children 2.5 kg, the ultrasound-guided subclavian approach is recommended due to its shorter procedure time and lower hematoma rate. Vein selection should depend on individual anatomy; if ultrasound-guided access fails or neck deformity limits jugular use, the subclavian route under ultrasound guidance is preferred. This procedure, however, requires skill and experience to prevent complications. Trial registration: This clinical trial was registered in the Iranian Registry of Clinical Trials (IRCT) with the code IRCT20230901059317N1(Registration date: 2024-02-16) Central Venous Access Open Jugular Ultrasound -Guided Subclavian Pediatric Low-Weight Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Central venous access is a fundamental therapeutic tool in pediatric medicine, particularly for patients admitted to intensive care units. This technique enables the administration of vasopressor agents, hypertonic solutions, total parenteral nutrition, transfusion of blood products, as well as frequent blood sampling and advanced hemodynamic monitoring[ 1 ]. However, central venous catheterization in neonates and children weighing less than 5 kilograms poses considerable challenges due to their unique anatomic and physiologic characteristics[ 2 ]. Smaller vessel calibers, closer proximity to vital structures such as arteries and nerves, increased vessel mobility compared to adults, and limited physiologic reserves all contribute to a heightened risk of complications in this vulnerable population[ 3 ]. Over the past decades, attention has increasingly focused on identifying the most suitable and safest approach to central venous access in these patients. Two principal techniques are commonly used: the open internal jugular vein approach and the ultrasound-guided subclavian approach[ 4 ]. The open jugular technique, a classic surgical procedure, involves making a small incision in the neck and directly visualizing the internal jugular vein for catheter insertion[ 5 ]. While this method allows for better bleeding control and direct identification of adjacent structures, it is also associated with higher risks of infection at the surgical site, potential injury to adjacent tissues, longer procedure times, and the possibility of scarring[ 6 ]. With advances in ultrasound technology and the adoption of minimally invasive interventions, ultrasound-guided subclavian vein cannulation has emerged as a popular and modern alternative. Real-time ultrasound guidance facilitates anatomical identification of the subclavian vein and enables safe needle advancement under direct visualization[ 7 ]. Several advantages have been reported for this approach, including reduced rates of unsuccessful attempts, lower risk of vascular or organ injury, decreased incidence of complications such as pneumothorax and hemothorax, and higher first-pass success rates[ 8 ]. Nevertheless, in infants and children weighing less than 5 kilograms, the small vessel size, shallow depth, and the close anatomical relationship to the subclavian artery and the lung apex maintain a significant risk of complications, underscoring the importance of operator expertise and technical proficiency[ 9 ]. While numerous studies have addressed the efficacy and safety of each technique individually in children and neonates, comparative clinical data focusing on patients weighing less than 5 kilograms remain limited and fragmented[ 10 ]. Selecting the optimal access route and technique can have a significant impact on immediate outcomes (such as procedural success, acute complications, and early infection) and long-term results (including late infection, thrombosis, and catheter displacement). Further complicating the decision are patient-related factors such as underlying health status, coagulopathy, the experience of the medical team, and the availability of advanced equipment[ 11 , 12 ]. Improvements in neonatal and pediatric intensive care have increased the survival of premature and critically ill infants, making the identification of safer, more effective, and less complication-prone approaches to central venous access a key research priority[ 13 ]. In this context, a direct comparison of the outcomes and complications associated with the open internal jugular and ultrasound-guided subclavian approaches will provide valuable evidence to inform clinical protocols and enhance quality of care[ 14 ]. Accordingly, the present study aims to compare the clinical outcomes and complications of central venous catheterization performed via these two major techniques in children weighing less than 5 kilograms. By identifying the strengths and limitations of each approach, this research seeks to provide actionable insights and scientific evidence that can guide optimal clinical decision-making in this particularly high-risk pediatric population. Ultimately, our findings may contribute to improving clinical outcomes and patient safety for low-weight infants treated in critical care settings. Material and methods Study Design This investigation was structured as a prospective, randomized clinical trial involving pediatrics, neonates and infants patients under five kilograms weighing who were candidates for central venous catheterization. The study was conducted at Mardani Azar Children’s Hospital, affiliated with Tabriz University of Medical Sciences. Data collection and patient enrollment took place over a one-year period, from winter 2022 to winter 2023. Sampling The sample size was estimated using the formula for comparing two independent groups. Based on this calculation and findings from a similar study, the incidence of complications was considered to be 30% in the open jugular group and 10% in the ultrasound-guided subclavian group, with a statistical power of 80% and a type I error of 0.05. The required sample size was determined to be 60 patients, accounting for a 10% attrition rate. However, given the higher number of eligible cases during the one-year study period, a total of 92 patients were ultimately enrolled and analyzed using a convenience sampling method. Eligibility Criteria Eligible participants for this study were pediatric patients weighing less than 5 kilograms who required central venous catheterization for clinical indications such as medication administration, parenteral nutrition, or advanced monitoring. Inclusion criteria encompassed children admitted to Mardani Azar Children’s Hospital during the study period and whose legal guardians provided informed consent. Patients were excluded if they had congenital or acquired coagulopathy, anatomical abnormalities of the neck or chest preventing catheter insertion, active local or systemic infection at the time of procedure, history of central venous catheterization complications, or if they were deemed unsuitable for either the open internal jugular or ultrasound-guided subclavian approach by the attending medical team. This approach ensured a homogenous study population while minimizing confounding variables and procedure-related risks. Randomization and blinding Ninety-two pediatric patients weighing less than five kilograms were randomly assigned in equal numbers to two groups using randomization.com in a double-blind manner. While the operating surgeon (the primary supervisor) was necessarily aware of the assigned intervention and therefore could not be blinded, both the biostatistician responsible for data analysis and the data-collecting physician (the resident author of the thesis) who recorded the relevant outcomes were blinded to the group allocations and the type of surgical technique performed on each patient. As a result, this study was conducted in a double-blind design. Procedure Patient Preparation All patients initially underwent either local anesthesia with lidocaine or sedation using sevoflurane gas, midazolam, or fentanyl, selected based on individual patient conditions. In the sedation group, anesthesia was managed either via mask ventilation or endotracheal intubation, as clinically appropriate. Each patient was positioned supine with a roll placed under the shoulder and the head rotated 45 degrees to the left. The neck was prepared and draped in a sterile fashion. A 5F ARROW central venous catheter was used in all cases. Initial Cannulation Attempt Cannulation of the right internal jugular vein was performed using the ultrasound-guided Seldinger technique, allowing a maximum of two attempts to minimize vessel manipulation and reduce the risk of potential complications that could otherwise act as confounding factors in the study outcomes. This procedure was performed for 138 patients, from which 92 successful cases were subsequently enrolled in the present study. For all patients, assessment for pneumothorax was performed post-procedure by an experienced operator using bedside ultrasound and portable chest radiography. Only patients with no evidence of pneumothorax proceeded to the study, and none were diagnosed with this complication at this stage. Open Internal Jugular Vein Group In the first group, open internal jugular catheterization was performed. A small skin incision was made on the neck, and the right internal jugular vein was dissected and isolated. A separate venotomy was then created, and the central venous catheter was inserted directly under direct vision without using a guidewire. The vein was repaired and the catheter was secured with non-absorbable sutures. In a minority of cases, distal ligation of the vein was performed as necessary. If initial placement was unsuccessful, the left internal jugular vein was utilized using the same technique. Ultrasound-Guided Subclavian Vein Group In the second group, ultrasound-guided subclavian vein cannulation was performed in accordance with the latest Armstrong radiology reference guidelines. The subclavian artery and vein were identified both in transverse and longitudinal planes beneath the ultrasound probe, below the clavicle and above the second rib. The subclavian vein was cannulated from a lateral approach under the clavicle. Once intravascular needle placement was confirmed by blood aspiration and ultrasound, a guidewire was advanced through the needle into the vein. Guidewire placement was further verified by ultrasound. The needle was then removed, and a dilator was passed over the guidewire. Following removal of the dilator, the central venous catheter was advanced over the guidewire into the subclavian vein. After confirmation of correct intravascular positioning, the guidewire was withdrawn, and the catheter was secured to the skin with suture. In cases of failed subclavian access, open internal jugular catheterization was then attempted. Post-Procedural Assessment and Follow-Up After catheter placement, all patients were evaluated intraoperatively for the position and possible complications including arterial cannulation, pneumothorax, hemothorax, ectopic catheter migration (outside the superior vena cava), and arrhythmia using both ultrasound and portable chest radiography. Post-operatively, patients were serially examined for thrombosis using echocardiography by an experienced operator, and monitored for hematoma, infection, and bleeding at the catheter site over a two-week period. All patients were thoroughly assessed for every possible complication to ensure that no adverse event was overlooked. Statistical Analysis All study data were analyzed using SPSS software version 16. Descriptive statistics, including frequency, percentage, mean, and standard deviation, were utilized to summarize the data. The Chi-square test was employed to compare qualitative variables between groups. For comparisons of quantitative variables, the one-way ANOVA, independent t-test, and the non-parametric Kruskal-Wallis test were applied as appropriate. A p-value less than 0.05 was considered statistically significant. Results A total of 92 patients were enrolled and randomly assigned into two groups of 46 each. All participants received their allocated intervention and were followed throughout the study. There was no loss to follow-up, withdrawal, or exclusion after randomization. Data analysis was performed for all 92 patients according to the intention-to-treat principle, and each participant was included in the final analysis. Thus, the attrition rate was zero, and the flow of participants was fully maintained from allocation through to analysis(Fig. 1 ). In this study, 92 patients were assessed in two groups of 46 each. The subclavian group included 18 females and 28 males, while the jugular group included 23 females and 23 males (P = 0.89). The mean age was 28.6 ± 3.9 days in the subclavian group and 23.26 ± 4.5 days in the jugular group (P = 0.76). The average weight was 3.13 ± 0.1 kg in the subclavian group and 2.96 ± 0.1 kg in the jugular group (P = 0.34). In terms of gestational status, the subclavian and jugular groups comprised 26 and 20 term infants, and 20 and 26 preterm infants, respectively (P = 0.29). Regarding anesthesia, 25 patients in the subclavian group and 14 in the jugular group underwent anesthesia with a face mask, while 21 in the subclavian group and 32 in the jugular group underwent endotracheal intubation (P = 0.19). The mean catheter placement time in the jugular group was significantly longer than in the subclavian group (41.19 ± 13.8 vs. 33.15 ± 12.12 minutes; P = 0.04)(Fig. 2 ). No cases of pneumothorax (P = 1), hemothorax (P = 1), bleeding (P = 1), arrhythmia (P = 1), occlusion (P = 1), infection (P = 1), or death (P = 1) were observed in either the jugular or subclavian groups, with all rates being zero. Thrombosis was documented in both groups, with 6 cases in the jugular group and 5 cases in the subclavian group, showing no significant difference (P = 0.95). Catheter migration occurred in 3 patients in the subclavian group but was not observed in the jugular group (P = 0.24, not significant). Hematoma developed in 6 patients in the jugular group but was absent in the subclavian group, representing a statistically significant difference (P = 0.02). Upper limb edema was seen in 3 patients from the subclavian group and not in the jugular group (P = 0.7, not significant). Failure occurred in 4 patients in the subclavian group and in none from the jugular group (P = 0.11, not significant)(Fig. 3 ). In the subgroup analysis based on body weight, it was found that all cases of catheterization failure (n = 4) and upper limb edema (n = 3) occurred exclusively in patients weighing less than 2.5 kg in the subclavian group. In this group, catheterization failure was significantly more frequent among patients weighing less than 2.5 kg compared to those above this threshold (P = 0.03). Similarly, the incidence of upper limb edema was significantly higher in patients under 2.5 kg (P = 0.014). In the jugular group, neither catheterization failure nor upper limb edema was observed in either weight subgroup (P = 1 for all comparisons)(Table 1 ). Table 1 Distribution of Catheterization Failure and Upper Limb Edema by Weight Subgroups in Jugular and Subclavian Groups Variables Jugular Group Subclavian Group < 2.5 kg ≥ 2.5 kg P Value < 2.5 kg ≥ 2.5 kg P Value Catheterization failure, n 0 0 1 4 0 0.03 Upper limb edema, n 0 0 1 3 0 0.014 Additionally, all cases of hematoma were observed exclusively in the first group (jugular approach), and all occurred in patients whose procedure duration exceeded 35 minutes. Therefore, we divided the jugular group into two subgroups based on procedure time ( 35 minutes), and found a statistically significant association between the incidence of hematoma and procedure duration (P = 0.041)(Fig. 4 ). Discussion The present study elucidated essential aspects regarding both the efficacy and safety of open jugular venous access versus ultrasound-guided subclavian approach for central venous catheterization in low-weight pediatric patients. Our findings highlighted a significant difference in catheter placement time—with the open jugular approach taking considerably longer than the ultrasound-guided subclavian method. This time discrepancy can be attributed to the technical challenges inherent in open surgical exposure of the internal jugular vein, particularly in neonates and infants with limited body mass and more fragile anatomical structures[ 15 ]. Factors contributing include the need for careful dissection of delicate tissues, difficulty identifying or cannulating smaller veins, and a potentially steeper learning curve for surgeons in such small patients[ 15 ]. In contrast, the real-time visualization provided by ultrasound guidance allows for more precise localization and cannulation with minimal tissue injury, resulting in a shorter procedure time[ 16 ]. In our previous randomized clinical trial involving 111 pediatric patients weighing less than 5 kg who required central venous catheterization, two approaches were assessed: the ultrasound-guided Seldinger technique (n = 55) and the open surgical cutdown method (n = 56). The success rate of catheter insertion with ultrasound guidance was 85.5%, and although the incidence of thrombosis, infection, and bleeding was numerically lower in the Seldinger group, these differences were statistically insignificant (p > 0.05). No cases of pneumothorax, hemothorax, catheter migration, or occlusion were observed, while two deaths (3.6%) in the open group were attributed to underlying medical conditions. Overall, ultrasound-guided catheterization in low-weight children demonstrated comparable safety to the open technique, with high procedural success and a low complication profile[ 17 ]. Importantly, there were no incidences of critical complications such as pneumothorax, hemothorax, major bleeding, arrhythmia, venous obstruction, infection, or mortality in either group. This absence of severe complications supports the fundamental safety of both approaches when performed by experienced teams. It aligns with prior pediatric studies indicating low rates of catastrophic events with proper technique and patient selection[ 18 ]. A striking observation in our results was the exclusive occurrence of hematomas in the open jugular group. While the risk of hematoma theoretically exists for both sites, our data clearly indicate a propensity for this complication after open jugular cannulation. Several factors may account for this: increased local dissection and manipulation, greater vulnerability of small-caliber veins to trauma and rupture, and potential difficulty controlling minor bleeding during open surgical access. Moreover, the fact that all hematomas occurred in cases where catheterization exceeded 35 minutes suggests a time-dependent risk—protracted procedures likely increase mechanical and hemostatic stress on tissues, predisposing to hematoma formation. In comparison, the precision inherent to ultrasound-guided subclavian access appears to minimize both vascular trauma and procedural time, consistent with growing evidence supporting ultrasound in pediatric vascular access[ 7 ]. According to the findings of the present study, four cases of catheterization failure were observed in the ultrasound-guided subclavian group, though the difference was not statistically significant compared with the open jugular group. However, since all four failures occurred in infants weighing less than 2.5 kg, we subsequently divided patients into two subgroups: those weighing below 2.5 kg and above 2.5 kg. Subgroup analysis revealed a significant difference between these weight categories—indicating that the probability of successful catheter insertion via the subclavian route is markedly lower in infants under 2.5 kg. Therefore, in such low-weight patients, open jugular venous access is recommended as the preferred method. Similarly, Karapinar et al. [ 19 ] reported comparable findings, suggesting that in younger pediatric patients, the risk of catheterization failure increases with the use of the subclavian vein, and consequently femoral or jugular cannulation should be considered instead. Nardi et al. [ 3 ] also described a significantly lower success rate for subclavian access compared to jugular or femoral routes in children weighing less than 5 kg, supporting our observation. Another noteworthy result was upper-limb edema, which occurred exclusively in the subclavian group and, again, only among children weighing less than 2.5 kg. Although the overall incidence of edema did not differ significantly between the two main groups, subgroup analysis based on weight demonstrated a significant association: the likelihood of upper-limb edema is higher in the subclavian approach for infants under 2.5 kg. Hence, the subclavian route should be avoided in this vulnerable patient population, where a lower body weight predisposes to mechanical and venous complications. It is also noteworthy that no statistically significant differences in other anticipated complications (including infection, major bleeding, and vascular events) were noted between the two groups. This contributes to the overall impression of safety for both methods, provided operators are skilled and the technique is tailored to the patient’s individual anatomy and clinical context. Thus, the optimal choice of central venous access route in low-weight pediatric patients should always be individualized—balancing anatomical, technical, and operator-related factors[ 20 , 21 ]. In the present study, no major adverse events—namely pneumothorax, hemothorax, bleeding, arrhythmia, catheter occlusion, infection, or mortality—were observed. Catheter-related thrombosis was identified in both groups through echocardiography performed two weeks after insertion; however, these findings did not interfere with catheter function and were considered unavoidable events rather than technique-dependent outcomes. Similar results were reported by Karapinar et al.[ 19 ], who documented thrombosis in 2.2% of patients without functional impairment, though pneumothorax and bleeding were noted in subclavian catheterization, prompting their recommendation of the jugular or femoral veins as first-line access sites. Casado-Flores et al[ 22 ]. reported three cases of catheter obstruction in children undergoing ultrasound-guided subclavian placement. Furthermore, Araujo et al[ 23 ]. demonstrated that complication rates are inversely related to operator experience, with first-year residents showing incidences as high as 58.8%. In line with these findings, the minimal complication rate observed in our study likely reflects the procedures being performed by a highly skilled and experienced operator. Additionally, our experience highlights the critical importance of procedure duration and operator expertise. All cases of hematoma in the jugular group were associated with procedures exceeding 35 minutes, emphasizing that prolonged attempts and technical difficulties amplify the risk of adverse outcomes. These findings advocate for targeted training, regular skill assessment, and the broader adoption of adjunct technologies such as real-time ultrasonography to optimize outcomes and minimize complications[ 21 ]. Conclusion Based on the findings of this study comparing two techniques for central venous catheter placement in pediatric patients weighing less than 5 kilograms, both approaches were associated with certain complications, yet the overall safety profile was acceptable when performed by skilled operators. Considering these outcomes, ultrasound-guided subclavian catheterization is recommended for children weighing more than 2.5 kilograms, owing to its reduced procedure time and lower risk of hematoma. The choice of venous access should be individualized according to the patient’s anatomical and clinical conditions. Consistent with previous evidence, in cases where ultrasound-guided catheterization fails via the subclavian vein or when neck deformity limits jugular access, it is advisable to attempt ultrasound-guided subclavian puncture rather than reverting to the open jugular technique. Nevertheless, successful and safe performance of this procedure requires advanced technical proficiency and experience to minimize procedure-related complications. Abbreviations ANOVA Analysis of Variance CVC Central Venous Catheter IRCT Iranian Registry of Clinical Trials ITT Intention–to–Treat LLM Large Language Model REC Research Ethics Committee SPSS Statistical Package for the Social Sciences Declarations Human Ethics and Consent to Participate declarations: Written informed consent was obtained from all participants after providing detailed explanations regarding the nature of the study. Strict confidentiality was maintained throughout the research, and no personal or identifying information about the patients was disclosed at any stage. It is noteworthy that all procedures performed in this study were solely for therapeutic purposes, with no additional financial burden imposed on the patients. Parents were informed that both catheterization methods were equally beneficial for central venous access and that there would be no difference in cost between the two techniques. The study protocol was approved by the Ethics Committee of Tabriz University of Medical Sciences under the code IR.TBZMED.REC.1402.610, and the clinical trial was registered in the Iranian Registry of Clinical Trials (IRCT) with the code IRCT20230901059317N1/ https://irct.behdasht.gov.ir/trial/72449. This study was conducted in full accordance with the principles of the Declaration of Helsinki. Given that the authors of the present study are non‑native English speakers and minor linguistic inaccuracies might have occurred during the initial drafting process, the manuscript was subsequently refined using a Large Language Model (LLM) such as ChatGPT to improve clarity and language quality. The authors affirm that this tool—and any similar language‑based applications—was used solely for stylistic enhancement and grammatical correction, and not for data analysis, primary writing, or any other component of the research process. Consent for publication: There are no patient personal data included in this manuscript. Availability of data and materials: The datasets used and analyzed during the current study are available from the corresponding author upon reasonable request. Competing interests: There are no financial, personal, or professional conflicts of interest related to this study. Funding: This study was financially supported by Tabriz University of Medical Sciences. Authors' contributions : All authors contributed to the study design, data collection, manuscript preparation, and final revision. Acknowledgements: The authors gratefully acknowledge the support of Tabriz University of Medical Sciences and sincerely thank the parents of the infants and children who participated in this study. References Vierboom, L., et al., Tunnelled central venous access devices in small children: a comparison of open vs. ultrasound-guided percutaneous insertion in children weighing ten kilograms or less. Journal of pediatric surgery, 2018. 53 (9): p. 1832-1838. Montes-Tapia, F., et al., Efficacy and safety of ultrasound-guided internal jugular vein catheterization in low birth weight newborn. Journal of pediatric surgery, 2016. 51 (10): p. 1700-1703. Nardi, N., et al., Effectiveness and complications of ultrasound-guided subclavian vein cannulation in children and neonates. Anaesthesia Critical Care & Pain Medicine, 2016. 35 (3): p. 209-213. 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Barone, G., et al., Centrally inserted central catheters in preterm neonates with weight below 1500 g by ultrasound-guided access to the brachio-cephalic vein. The Journal of Vascular Access, 2021. 22 (3): p. 344-352. Liu, W., et al., Combined short‐and long‐axis method for internal jugular vein catheterization in premature newborns: A randomized controlled trial. Acta Anaesthesiologica Scandinavica, 2021. 65 (3): p. 420-427. Gong, X., et al., Comparison of the ultrasound-guided supraclavicular and infraclavicular approaches for subclavian vein cannulation in children with congenital heart disease. Journal of Cardiothoracic and Vascular Anesthesia, 2024. 38 (7): p. 1477-1483. Barone, G., et al., Neo-ECHOTIP: a structured protocol for ultrasound-based tip navigation and tip location during placement of central venous access devices in neonates . 2022, Sage Publications Sage UK: London, England. p. 679-688. Disma, N.M. and M. Pittiruti, Evidence based rationale for ultrasound guided vascular access in children , in Vascular Access in Neonates and Children . 2022, Springer. p. 25-29. Spagnuolo, F. and T. Vacchiano, Ultrasound-guided cannulation of the brachiocephalic vein in newborns: a novel approach with a supraclavicular view for tip navigation and tip location. The Journal of Vascular Access, 2022. 23 (4): p. 515-523. Mghirbi, O., et al., Ultrasound-guided cannulation of the brachiocephalic vein in neonates: Feasibility and safety. The Journal of Vascular Access, 2024: p. 11297298251349037. Seçici, S., Landmark guided internal jugular vein catheterization in infants undergoing congenital heart surgery. The European Research Journal, 2021. 7 (4): p. 375-379. Gurel, S., A. Gözen, and M.S. Bektas, Central Subclavian Catheterization in Newborns: Single-Center Experience. Journal of Child Science, 2022. 12 (01): p. e5-e8. Farhadi, E., et al., Comparison of open and ultrasound-guided placement of central venous catheter in children weighing less than five kilograms; a randomized clinical trial. Academic Radiology, 2023. 30 (7): p. 1419-1425. Merchaoui, Z., et al., Ultrasound guided percutaneous catheterization of the brachiocephalic vein by small caliber catheter: An alternative to epicutaneo-caval catheter in newborn and premature infants. The Journal of Vascular Access, 2023. 24 (3): p. 487-491. Karapinar, B. and A. Cura, Complications of central venous catheterization in critically ill children. Pediatrics International, 2007. 49 (5): p. 593-599. Sangsari, R., et al., Peripherally Inserted Central Catheter Tip Malposition in Neonates: A Comparison of Placement in the Head & Neck, Upper Extremity, and Lower Extremity. IJ Pediatrics, 2024. 34 (34). Jørgensen, M.H., et al., Safety of high‐volume plasmapheresis in children with acute liver failure. Journal of Pediatric Gastroenterology and Nutrition, 2021. 72 (6): p. 815-819. Casado-Flores, J., et al., Subclavian vein catheterization in critically ill children: analysis of 322 cannulations. Intensive care medicine, 1991. 17 (6): p. 350-354. Araujo, C.C., M.C. Lima, and G.H. Falbo, Percutaneous subclavian central venous catheterization in children and adolescents: success, complications and related factors. Jornal de pediatria, 2007. 83 : p. 64-70. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7933826","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":541006888,"identity":"43c55fae-a407-495e-ba28-4fcf4644efe3","order_by":0,"name":"Ebrahim Farhadi","email":"","orcid":"","institution":"Tabriz University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Ebrahim","middleName":"","lastName":"Farhadi","suffix":""},{"id":541006889,"identity":"5769e089-978e-4fca-bb02-3168432dad32","order_by":1,"name":"Mohsen Rezaee","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA90lEQVRIiWNgGAWjYFACHiT2hwobIMnYeIBoLYwzzqSBqAbitTDzthwGM/Bq0W3vPfzh4457cvLthw8+nNlw3m5t+2GgLTU20bi0mJ05lyY580yxMWNPWrLBxx23k7edSQRqOZaW24BLy40cM2betoTEZoYcM6De28lmB4BaGBsO49Ni/PlvW0J9G//77795284lm51/SFCLgTRjW0ICj0QOG9C6A3ZmNwjZcuaMmWRvW4LhDIlnxpIzziQnmN0A2pKAzy/He4w//GxLkJfvT3744UOFnb3Z+fSHDz7U2ODUggESwSoTiFUOAvakKB4Fo2AUjIKRAQATaGjDN0cRlwAAAABJRU5ErkJggg==","orcid":"","institution":"Tabriz University of Medical Sciences","correspondingAuthor":true,"prefix":"","firstName":"Mohsen","middleName":"","lastName":"Rezaee","suffix":""},{"id":541006890,"identity":"3da65c02-df35-44a1-872a-cb860cb0df35","order_by":2,"name":"Saeed Aslanabadi","email":"","orcid":"","institution":"Tabriz University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Saeed","middleName":"","lastName":"Aslanabadi","suffix":""},{"id":541006891,"identity":"eb5774e8-fcd8-4057-b546-f2a77f71543e","order_by":3,"name":"Davoud Badebarin","email":"","orcid":"","institution":"Tabriz University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Davoud","middleName":"","lastName":"Badebarin","suffix":""},{"id":541006892,"identity":"386f38a8-a542-4260-b0d0-be59fee0c756","order_by":4,"name":"Vahid hamzei","email":"","orcid":"","institution":"Tabriz University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Vahid","middleName":"","lastName":"hamzei","suffix":""}],"badges":[],"createdAt":"2025-10-23 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08:51:44","extension":"xml","order_by":11,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":67655,"visible":true,"origin":"","legend":"","description":"","filename":"6d533b15c4914f59bb6580faba29060c1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7933826/v1/af6410ca4a95fb8471ce3e11.xml"},{"id":95810103,"identity":"ead999da-1237-49a0-8581-859a6e52a916","added_by":"auto","created_at":"2025-11-13 08:51:47","extension":"html","order_by":12,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":75640,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7933826/v1/a25cfcb36515727d2046191f.html"},{"id":95810120,"identity":"89179095-0d35-43c0-9144-48b2f3259b77","added_by":"auto","created_at":"2025-11-13 08:51:51","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":27124,"visible":true,"origin":"","legend":"\u003cp\u003ePatient enrollment and follow-up process based on the CONSORT flowchart\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7933826/v1/dfb665ab8fb276d80e200319.png"},{"id":95810050,"identity":"3ea9300c-e18a-46d0-b79f-3c242b29a30c","added_by":"auto","created_at":"2025-11-13 08:51:43","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":39306,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of Catheter Placement Time Between Jugular and Subclavian Groups\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7933826/v1/63180a3ed82b8d8802c3465b.png"},{"id":95810198,"identity":"b8a17007-38cb-44a9-b83d-91da06b9ffad","added_by":"auto","created_at":"2025-11-13 08:52:00","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":34762,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of Complications Between Jugular and Subclavian Groups\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7933826/v1/9c148ee01e1964c0a45da1bd.png"},{"id":95810026,"identity":"2ffcda0a-2e61-41ae-b4f0-b1eb93f13eac","added_by":"auto","created_at":"2025-11-13 08:51:40","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":30819,"visible":true,"origin":"","legend":"\u003cp\u003eIncidence of Hematoma According to Procedure Duration in the Jugular Group\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-7933826/v1/c31061581f16440050c3a67f.png"},{"id":96238968,"identity":"5d5dff6a-af04-4848-bef6-6658dfbeb8c8","added_by":"auto","created_at":"2025-11-19 06:58:52","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":760662,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7933826/v1/dd75f23c-1047-4b8e-8467-4e73e56a387d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Comparative Outcomes of Central Venous Access via Open Jugular and Ultrasound-Guided Subclavian Approaches in Low-Weight Pediatric Patients: A Study with Secondary Outcomes","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCentral venous access is a fundamental therapeutic tool in pediatric medicine, particularly for patients admitted to intensive care units. This technique enables the administration of vasopressor agents, hypertonic solutions, total parenteral nutrition, transfusion of blood products, as well as frequent blood sampling and advanced hemodynamic monitoring[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. However, central venous catheterization in neonates and children weighing less than 5 kilograms poses considerable challenges due to their unique anatomic and physiologic characteristics[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Smaller vessel calibers, closer proximity to vital structures such as arteries and nerves, increased vessel mobility compared to adults, and limited physiologic reserves all contribute to a heightened risk of complications in this vulnerable population[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOver the past decades, attention has increasingly focused on identifying the most suitable and safest approach to central venous access in these patients. Two principal techniques are commonly used: the open internal jugular vein approach and the ultrasound-guided subclavian approach[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The open jugular technique, a classic surgical procedure, involves making a small incision in the neck and directly visualizing the internal jugular vein for catheter insertion[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. While this method allows for better bleeding control and direct identification of adjacent structures, it is also associated with higher risks of infection at the surgical site, potential injury to adjacent tissues, longer procedure times, and the possibility of scarring[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e With advances in ultrasound technology and the adoption of minimally invasive interventions, ultrasound-guided subclavian vein cannulation has emerged as a popular and modern alternative. Real-time ultrasound guidance facilitates anatomical identification of the subclavian vein and enables safe needle advancement under direct visualization[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Several advantages have been reported for this approach, including reduced rates of unsuccessful attempts, lower risk of vascular or organ injury, decreased incidence of complications such as pneumothorax and hemothorax, and higher first-pass success rates[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Nevertheless, in infants and children weighing less than 5 kilograms, the small vessel size, shallow depth, and the close anatomical relationship to the subclavian artery and the lung apex maintain a significant risk of complications, underscoring the importance of operator expertise and technical proficiency[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eWhile numerous studies have addressed the efficacy and safety of each technique individually in children and neonates, comparative clinical data focusing on patients weighing less than 5 kilograms remain limited and fragmented[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Selecting the optimal access route and technique can have a significant impact on immediate outcomes (such as procedural success, acute complications, and early infection) and long-term results (including late infection, thrombosis, and catheter displacement). Further complicating the decision are patient-related factors such as underlying health status, coagulopathy, the experience of the medical team, and the availability of advanced equipment[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eImprovements in neonatal and pediatric intensive care have increased the survival of premature and critically ill infants, making the identification of safer, more effective, and less complication-prone approaches to central venous access a key research priority[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In this context, a direct comparison of the outcomes and complications associated with the open internal jugular and ultrasound-guided subclavian approaches will provide valuable evidence to inform clinical protocols and enhance quality of care[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAccordingly, the present study aims to compare the clinical outcomes and complications of central venous catheterization performed via these two major techniques in children weighing less than 5 kilograms. By identifying the strengths and limitations of each approach, this research seeks to provide actionable insights and scientific evidence that can guide optimal clinical decision-making in this particularly high-risk pediatric population. Ultimately, our findings may contribute to improving clinical outcomes and patient safety for low-weight infants treated in critical care settings.\u003c/p\u003e"},{"header":"Material and methods","content":"\u003cp\u003e\u003cstrong\u003eStudy Design\u003c/strong\u003e\u003cp\u003eThis investigation was structured as a prospective, randomized clinical trial involving pediatrics, neonates and infants patients under five kilograms weighing who were candidates for central venous catheterization. The study was conducted at Mardani Azar Children\u0026rsquo;s Hospital, affiliated with Tabriz University of Medical Sciences. Data collection and patient enrollment took place over a one-year period, from winter 2022 to winter 2023.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eSampling\u003c/strong\u003e\u003cp\u003eThe sample size was estimated using the formula for comparing two independent groups. Based on this calculation and findings from a similar study, the incidence of complications was considered to be 30% in the open jugular group and 10% in the ultrasound-guided subclavian group, with a statistical power of 80% and a type I error of 0.05. The required sample size was determined to be 60 patients, accounting for a 10% attrition rate. However, given the higher number of eligible cases during the one-year study period, a total of 92 patients were ultimately enrolled and analyzed using a convenience sampling method.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eEligibility Criteria\u003c/strong\u003e\u003cp\u003eEligible participants for this study were pediatric patients weighing less than 5 kilograms who required central venous catheterization for clinical indications such as medication administration, parenteral nutrition, or advanced monitoring. Inclusion criteria encompassed children admitted to Mardani Azar Children\u0026rsquo;s Hospital during the study period and whose legal guardians provided informed consent. Patients were excluded if they had congenital or acquired coagulopathy, anatomical abnormalities of the neck or chest preventing catheter insertion, active local or systemic infection at the time of procedure, history of central venous catheterization complications, or if they were deemed unsuitable for either the open internal jugular or ultrasound-guided subclavian approach by the attending medical team. This approach ensured a homogenous study population while minimizing confounding variables and procedure-related risks.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eRandomization and blinding\u003c/strong\u003e\u003cp\u003eNinety-two pediatric patients weighing less than five kilograms were randomly assigned in equal numbers to two groups using randomization.com in a double-blind manner. While the operating surgeon (the primary supervisor) was necessarily aware of the assigned intervention and therefore could not be blinded, both the biostatistician responsible for data analysis and the data-collecting physician (the resident author of the thesis) who recorded the relevant outcomes were blinded to the group allocations and the type of surgical technique performed on each patient. As a result, this study was conducted in a double-blind design.\u003c/p\u003e\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eProcedure\u003c/h2\u003e\u003cp\u003e\u003cstrong\u003ePatient Preparation\u003c/strong\u003e\u003cp\u003eAll patients initially underwent either local anesthesia with lidocaine or sedation using sevoflurane gas, midazolam, or fentanyl, selected based on individual patient conditions. In the sedation group, anesthesia was managed either via mask ventilation or endotracheal intubation, as clinically appropriate. Each patient was positioned supine with a roll placed under the shoulder and the head rotated 45 degrees to the left. The neck was prepared and draped in a sterile fashion. A 5F ARROW central venous catheter was used in all cases.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eInitial Cannulation Attempt\u003c/strong\u003e\u003cp\u003eCannulation of the right internal jugular vein was performed using the ultrasound-guided Seldinger technique, allowing a maximum of two attempts to minimize vessel manipulation and reduce the risk of potential complications that could otherwise act as confounding factors in the study outcomes. This procedure was performed for 138 patients, from which 92 successful cases were subsequently enrolled in the present study. For all patients, assessment for pneumothorax was performed post-procedure by an experienced operator using bedside ultrasound and portable chest radiography. Only patients with no evidence of pneumothorax proceeded to the study, and none were diagnosed with this complication at this stage.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eOpen Internal Jugular Vein Group\u003c/strong\u003e\u003cp\u003eIn the first group, open internal jugular catheterization was performed. A small skin incision was made on the neck, and the right internal jugular vein was dissected and isolated. A separate venotomy was then created, and the central venous catheter was inserted directly under direct vision without using a guidewire. The vein was repaired and the catheter was secured with non-absorbable sutures. In a minority of cases, distal ligation of the vein was performed as necessary. If initial placement was unsuccessful, the left internal jugular vein was utilized using the same technique.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eUltrasound-Guided Subclavian Vein Group\u003c/strong\u003e\u003cp\u003e In the second group, ultrasound-guided subclavian vein cannulation was performed in accordance with the latest Armstrong radiology reference guidelines. The subclavian artery and vein were identified both in transverse and longitudinal planes beneath the ultrasound probe, below the clavicle and above the second rib. The subclavian vein was cannulated from a lateral approach under the clavicle. Once intravascular needle placement was confirmed by blood aspiration and ultrasound, a guidewire was advanced through the needle into the vein. Guidewire placement was further verified by ultrasound. The needle was then removed, and a dilator was passed over the guidewire. Following removal of the dilator, the central venous catheter was advanced over the guidewire into the subclavian vein. After confirmation of correct intravascular positioning, the guidewire was withdrawn, and the catheter was secured to the skin with suture. In cases of failed subclavian access, open internal jugular catheterization was then attempted.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003ePost-Procedural Assessment and Follow-Up\u003c/strong\u003e\u003cp\u003eAfter catheter placement, all patients were evaluated intraoperatively for the position and possible complications including arterial cannulation, pneumothorax, hemothorax, ectopic catheter migration (outside the superior vena cava), and arrhythmia using both ultrasound and portable chest radiography. Post-operatively, patients were serially examined for thrombosis using echocardiography by an experienced operator, and monitored for hematoma, infection, and bleeding at the catheter site over a two-week period. All patients were thoroughly assessed for every possible complication to ensure that no adverse event was overlooked.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eStatistical Analysis\u003c/strong\u003e\u003cp\u003eAll study data were analyzed using SPSS software version 16. Descriptive statistics, including frequency, percentage, mean, and standard deviation, were utilized to summarize the data. The Chi-square test was employed to compare qualitative variables between groups. For comparisons of quantitative variables, the one-way ANOVA, independent t-test, and the non-parametric Kruskal-Wallis test were applied as appropriate. A p-value less than 0.05 was considered statistically significant.\u003c/p\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 92 patients were enrolled and randomly assigned into two groups of 46 each. All participants received their allocated intervention and were followed throughout the study. There was no loss to follow-up, withdrawal, or exclusion after randomization. Data analysis was performed for all 92 patients according to the intention-to-treat principle, and each participant was included in the final analysis. Thus, the attrition rate was zero, and the flow of participants was fully maintained from allocation through to analysis(Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eIn this study, 92 patients were assessed in two groups of 46 each. The subclavian group included 18 females and 28 males, while the jugular group included 23 females and 23 males (P\u0026thinsp;=\u0026thinsp;0.89). The mean age was 28.6\u0026thinsp;\u0026plusmn;\u0026thinsp;3.9 days in the subclavian group and 23.26\u0026thinsp;\u0026plusmn;\u0026thinsp;4.5 days in the jugular group (P\u0026thinsp;=\u0026thinsp;0.76). The average weight was 3.13\u0026thinsp;\u0026plusmn;\u0026thinsp;0.1 kg in the subclavian group and 2.96\u0026thinsp;\u0026plusmn;\u0026thinsp;0.1 kg in the jugular group (P\u0026thinsp;=\u0026thinsp;0.34). In terms of gestational status, the subclavian and jugular groups comprised 26 and 20 term infants, and 20 and 26 preterm infants, respectively (P\u0026thinsp;=\u0026thinsp;0.29). Regarding anesthesia, 25 patients in the subclavian group and 14 in the jugular group underwent anesthesia with a face mask, while 21 in the subclavian group and 32 in the jugular group underwent endotracheal intubation (P\u0026thinsp;=\u0026thinsp;0.19).\u003c/p\u003e\u003cp\u003eThe mean catheter placement time in the jugular group was significantly longer than in the subclavian group (41.19\u0026thinsp;\u0026plusmn;\u0026thinsp;13.8 vs. 33.15\u0026thinsp;\u0026plusmn;\u0026thinsp;12.12 minutes; P\u0026thinsp;=\u0026thinsp;0.04)(Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eNo cases of pneumothorax (P\u0026thinsp;=\u0026thinsp;1), hemothorax (P\u0026thinsp;=\u0026thinsp;1), bleeding (P\u0026thinsp;=\u0026thinsp;1), arrhythmia (P\u0026thinsp;=\u0026thinsp;1), occlusion (P\u0026thinsp;=\u0026thinsp;1), infection (P\u0026thinsp;=\u0026thinsp;1), or death (P\u0026thinsp;=\u0026thinsp;1) were observed in either the jugular or subclavian groups, with all rates being zero. Thrombosis was documented in both groups, with 6 cases in the jugular group and 5 cases in the subclavian group, showing no significant difference (P\u0026thinsp;=\u0026thinsp;0.95). Catheter migration occurred in 3 patients in the subclavian group but was not observed in the jugular group (P\u0026thinsp;=\u0026thinsp;0.24, not significant). Hematoma developed in 6 patients in the jugular group but was absent in the subclavian group, representing a statistically significant difference (P\u0026thinsp;=\u0026thinsp;0.02). Upper limb edema was seen in 3 patients from the subclavian group and not in the jugular group (P\u0026thinsp;=\u0026thinsp;0.7, not significant). Failure occurred in 4 patients in the subclavian group and in none from the jugular group (P\u0026thinsp;=\u0026thinsp;0.11, not significant)(Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eIn the subgroup analysis based on body weight, it was found that all cases of catheterization failure (n\u0026thinsp;=\u0026thinsp;4) and upper limb edema (n\u0026thinsp;=\u0026thinsp;3) occurred exclusively in patients weighing less than 2.5 kg in the subclavian group. In this group, catheterization failure was significantly more frequent among patients weighing less than 2.5 kg compared to those above this threshold (P\u0026thinsp;=\u0026thinsp;0.03). Similarly, the incidence of upper limb edema was significantly higher in patients under 2.5 kg (P\u0026thinsp;=\u0026thinsp;0.014). In the jugular group, neither catheterization failure nor upper limb edema was observed in either weight subgroup (P\u0026thinsp;=\u0026thinsp;1 for all comparisons)(Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDistribution of Catheterization Failure and Upper Limb Edema by Weight Subgroups in Jugular and Subclavian Groups\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eVariables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003eJugular Group\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e\u003cp\u003eSubclavian Group\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;2.5 kg\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;2.5 kg\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP Value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;2.5 kg\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;2.5 kg\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eP Value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCatheterization failure, n\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.03\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUpper limb edema, n\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.014\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAdditionally, all cases of hematoma were observed exclusively in the first group (jugular approach), and all occurred in patients whose procedure duration exceeded 35 minutes. Therefore, we divided the jugular group into two subgroups based on procedure time (\u0026lt;\u0026thinsp;35 minutes and \u0026gt;\u0026thinsp;35 minutes), and found a statistically significant association between the incidence of hematoma and procedure duration (P\u0026thinsp;=\u0026thinsp;0.041)(Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe present study elucidated essential aspects regarding both the efficacy and safety of open jugular venous access versus ultrasound-guided subclavian approach for central venous catheterization in low-weight pediatric patients. Our findings highlighted a significant difference in catheter placement time\u0026mdash;with the open jugular approach taking considerably longer than the ultrasound-guided subclavian method. This time discrepancy can be attributed to the technical challenges inherent in open surgical exposure of the internal jugular vein, particularly in neonates and infants with limited body mass and more fragile anatomical structures[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Factors contributing include the need for careful dissection of delicate tissues, difficulty identifying or cannulating smaller veins, and a potentially steeper learning curve for surgeons in such small patients[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. In contrast, the real-time visualization provided by ultrasound guidance allows for more precise localization and cannulation with minimal tissue injury, resulting in a shorter procedure time[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn our previous randomized clinical trial involving 111 pediatric patients weighing less than 5 kg who required central venous catheterization, two approaches were assessed: the ultrasound-guided Seldinger technique (n\u0026thinsp;=\u0026thinsp;55) and the open surgical cutdown method (n\u0026thinsp;=\u0026thinsp;56). The success rate of catheter insertion with ultrasound guidance was 85.5%, and although the incidence of thrombosis, infection, and bleeding was numerically lower in the Seldinger group, these differences were statistically insignificant (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). No cases of pneumothorax, hemothorax, catheter migration, or occlusion were observed, while two deaths (3.6%) in the open group were attributed to underlying medical conditions. Overall, ultrasound-guided catheterization in low-weight children demonstrated comparable safety to the open technique, with high procedural success and a low complication profile[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eImportantly, there were no incidences of critical complications such as pneumothorax, hemothorax, major bleeding, arrhythmia, venous obstruction, infection, or mortality in either group. This absence of severe complications supports the fundamental safety of both approaches when performed by experienced teams. It aligns with prior pediatric studies indicating low rates of catastrophic events with proper technique and patient selection[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eA striking observation in our results was the exclusive occurrence of hematomas in the open jugular group. While the risk of hematoma theoretically exists for both sites, our data clearly indicate a propensity for this complication after open jugular cannulation. Several factors may account for this: increased local dissection and manipulation, greater vulnerability of small-caliber veins to trauma and rupture, and potential difficulty controlling minor bleeding during open surgical access. Moreover, the fact that all hematomas occurred in cases where catheterization exceeded 35 minutes suggests a time-dependent risk\u0026mdash;protracted procedures likely increase mechanical and hemostatic stress on tissues, predisposing to hematoma formation. In comparison, the precision inherent to ultrasound-guided subclavian access appears to minimize both vascular trauma and procedural time, consistent with growing evidence supporting ultrasound in pediatric vascular access[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAccording to the findings of the present study, four cases of catheterization failure were observed in the ultrasound-guided subclavian group, though the difference was not statistically significant compared with the open jugular group. However, since all four failures occurred in infants weighing less than 2.5 kg, we subsequently divided patients into two subgroups: those weighing below 2.5 kg and above 2.5 kg. Subgroup analysis revealed a significant difference between these weight categories\u0026mdash;indicating that the probability of successful catheter insertion via the subclavian route is markedly lower in infants under 2.5 kg. Therefore, in such low-weight patients, open jugular venous access is recommended as the preferred method. Similarly, Karapinar et al. [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] reported comparable findings, suggesting that in younger pediatric patients, the risk of catheterization failure increases with the use of the subclavian vein, and consequently femoral or jugular cannulation should be considered instead. Nardi et al. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] also described a significantly lower success rate for subclavian access compared to jugular or femoral routes in children weighing less than 5 kg, supporting our observation. Another noteworthy result was upper-limb edema, which occurred exclusively in the subclavian group and, again, only among children weighing less than 2.5 kg. Although the overall incidence of edema did not differ significantly between the two main groups, subgroup analysis based on weight demonstrated a significant association: the likelihood of upper-limb edema is higher in the subclavian approach for infants under 2.5 kg. Hence, the subclavian route should be avoided in this vulnerable patient population, where a lower body weight predisposes to mechanical and venous complications.\u003c/p\u003e\u003cp\u003eIt is also noteworthy that no statistically significant differences in other anticipated complications (including infection, major bleeding, and vascular events) were noted between the two groups. This contributes to the overall impression of safety for both methods, provided operators are skilled and the technique is tailored to the patient\u0026rsquo;s individual anatomy and clinical context. Thus, the optimal choice of central venous access route in low-weight pediatric patients should always be individualized\u0026mdash;balancing anatomical, technical, and operator-related factors[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn the present study, no major adverse events\u0026mdash;namely pneumothorax, hemothorax, bleeding, arrhythmia, catheter occlusion, infection, or mortality\u0026mdash;were observed. Catheter-related thrombosis was identified in both groups through echocardiography performed two weeks after insertion; however, these findings did not interfere with catheter function and were considered unavoidable events rather than technique-dependent outcomes. Similar results were reported by Karapinar et al.[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], who documented thrombosis in 2.2% of patients without functional impairment, though pneumothorax and bleeding were noted in subclavian catheterization, prompting their recommendation of the jugular or femoral veins as first-line access sites. Casado-Flores et al[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. reported three cases of catheter obstruction in children undergoing ultrasound-guided subclavian placement. Furthermore, Araujo et al[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. demonstrated that complication rates are inversely related to operator experience, with first-year residents showing incidences as high as 58.8%. In line with these findings, the minimal complication rate observed in our study likely reflects the procedures being performed by a highly skilled and experienced operator.\u003c/p\u003e\u003cp\u003eAdditionally, our experience highlights the critical importance of procedure duration and operator expertise. All cases of hematoma in the jugular group were associated with procedures exceeding 35 minutes, emphasizing that prolonged attempts and technical difficulties amplify the risk of adverse outcomes. These findings advocate for targeted training, regular skill assessment, and the broader adoption of adjunct technologies such as real-time ultrasonography to optimize outcomes and minimize complications[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eBased on the findings of this study comparing two techniques for central venous catheter placement in pediatric patients weighing less than 5 kilograms, both approaches were associated with certain complications, yet the overall safety profile was acceptable when performed by skilled operators. Considering these outcomes, ultrasound-guided subclavian catheterization is recommended for children weighing more than 2.5 kilograms, owing to its reduced procedure time and lower risk of hematoma. The choice of venous access should be individualized according to the patient\u0026rsquo;s anatomical and clinical conditions. Consistent with previous evidence, in cases where ultrasound-guided catheterization fails via the subclavian vein or when neck deformity limits jugular access, it is advisable to attempt ultrasound-guided subclavian puncture rather than reverting to the open jugular technique. Nevertheless, successful and safe performance of this procedure requires advanced technical proficiency and experience to minimize procedure-related complications.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eANOVA\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAnalysis of Variance\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eCVC\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCentral Venous Catheter\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eIRCT\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eIranian Registry of Clinical Trials\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eITT\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eIntention\u0026ndash;to\u0026ndash;Treat\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eLLM\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eLarge Language Model\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eREC\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eResearch Ethics Committee\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eSPSS\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eStatistical Package for the Social Sciences\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eHuman Ethics and Consent to Participate declarations:\u003c/strong\u003e Written informed consent was obtained from all participants after providing detailed explanations regarding the nature of the study. Strict confidentiality was maintained throughout the research, and no personal or identifying information about the patients was disclosed at any stage. It is noteworthy that all procedures performed in this study were solely for therapeutic purposes, with no additional financial burden imposed on the patients. Parents were informed that both catheterization methods were equally beneficial for central venous access and that there would be no difference in cost between the two techniques. The study protocol was approved by the Ethics Committee of Tabriz University of Medical Sciences under the code IR.TBZMED.REC.1402.610, and the clinical trial was registered in the Iranian Registry of Clinical Trials (IRCT) with the code IRCT20230901059317N1/ https://irct.behdasht.gov.ir/trial/72449.\u0026nbsp;This study was conducted in full accordance with the principles of the Declaration of Helsinki.\u0026nbsp;Given that the authors of the present study are non‑native English speakers and minor linguistic inaccuracies might have occurred during the initial drafting process, the manuscript was subsequently refined using a Large Language Model (LLM) such as ChatGPT to improve clarity and language quality. The authors affirm that this tool—and any similar language‑based applications—was used solely for stylistic enhancement and grammatical correction, and not for data analysis, primary writing, or any other component of the research process.\u003c/p\u003e\n\u003cp\u003eConsent for publication: There are no patient personal data included in this manuscript.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials: The datasets used and analyzed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003eCompeting interests: There are no financial, personal, or professional conflicts of interest related to this study.\u003c/p\u003e\n\u003cp\u003eFunding: This study was financially supported by Tabriz University of Medical Sciences.\u003c/p\u003e\n\u003cp\u003eAuthors' contributions : All authors contributed to the study design, data collection, manuscript preparation, and final revision.\u003c/p\u003e\n\u003cp\u003eAcknowledgements: The authors gratefully acknowledge the support of Tabriz University of Medical Sciences and sincerely thank the parents of the infants and children who participated in this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eVierboom, L., et al., \u003cem\u003eTunnelled central venous access devices in small children: a comparison of open vs. ultrasound-guided percutaneous insertion in children weighing ten kilograms or less.\u003c/em\u003e Journal of pediatric surgery, 2018. \u003cstrong\u003e53\u003c/strong\u003e(9): p. 1832-1838.\u003c/li\u003e\n \u003cli\u003eMontes-Tapia, F., et al., \u003cem\u003eEfficacy and safety of ultrasound-guided internal jugular vein catheterization in low birth weight newborn.\u003c/em\u003e Journal of pediatric surgery, 2016. \u003cstrong\u003e51\u003c/strong\u003e(10): p. 1700-1703.\u003c/li\u003e\n \u003cli\u003eNardi, N., et al., \u003cem\u003eEffectiveness and complications of ultrasound-guided subclavian vein cannulation in children and neonates.\u003c/em\u003e Anaesthesia Critical Care \u0026amp; Pain Medicine, 2016. \u003cstrong\u003e35\u003c/strong\u003e(3): p. 209-213.\u003c/li\u003e\n \u003cli\u003eKeskin, H., et al., \u003cem\u003eSyringe-free, long-axis in-plane versus short-axis classic out-of-plane approach for ultrasound-guided internal jugular vein catheter placement in critically ill children: a prospective randomized study.\u003c/em\u003e Journal of Cardiothoracic and Vascular Anesthesia, 2021. \u003cstrong\u003e35\u003c/strong\u003e(7): p. 2094-2099.\u003c/li\u003e\n \u003cli\u003eAytekin, C., et al., \u003cem\u003eUltrasound-guided brachiocephalic vein catheterization in infants weighing less than five kilograms.\u003c/em\u003e The Journal of Vascular Access, 2015. \u003cstrong\u003e16\u003c/strong\u003e(6): p. 512-514.\u003c/li\u003e\n \u003cli\u003eMerchaoui, Z., et al., \u003cem\u003eSupraclavicular approach to ultrasound-guided brachiocephalic vein cannulation in children and neonates.\u003c/em\u003e Frontiers in Pediatrics, 2017. \u003cstrong\u003e5\u003c/strong\u003e: p. 211.\u003c/li\u003e\n \u003cli\u003eAcosta, C. and G. Tusman, \u003cem\u003eUltrasound-guided brachiocephalic vein access in neonates and pediatric patients.\u003c/em\u003e Revista Espa\u0026ntilde;ola de Anestesiolog\u0026iacute;a y Reanimaci\u0026oacute;n (English Edition), 2021. \u003cstrong\u003e68\u003c/strong\u003e(10): p. 584-591.\u003c/li\u003e\n \u003cli\u003eBarone, G., et al., \u003cem\u003eCentrally inserted central catheters in preterm neonates with weight below 1500 g by ultrasound-guided access to the brachio-cephalic vein.\u003c/em\u003e The Journal of Vascular Access, 2021. \u003cstrong\u003e22\u003c/strong\u003e(3): p. 344-352.\u003c/li\u003e\n \u003cli\u003eLiu, W., et al., \u003cem\u003eCombined short‐and long‐axis method for internal jugular vein catheterization in premature newborns: A randomized controlled trial.\u003c/em\u003e Acta Anaesthesiologica Scandinavica, 2021. \u003cstrong\u003e65\u003c/strong\u003e(3): p. 420-427.\u003c/li\u003e\n \u003cli\u003eGong, X., et al., \u003cem\u003eComparison of the ultrasound-guided supraclavicular and infraclavicular approaches for subclavian vein cannulation in children with congenital heart disease.\u003c/em\u003e Journal of Cardiothoracic and Vascular Anesthesia, 2024. \u003cstrong\u003e38\u003c/strong\u003e(7): p. 1477-1483.\u003c/li\u003e\n \u003cli\u003eBarone, G., et al., \u003cem\u003eNeo-ECHOTIP: a structured protocol for ultrasound-based tip navigation and tip location during placement of central venous access devices in neonates\u003c/em\u003e. 2022, Sage Publications Sage UK: London, England. p. 679-688.\u003c/li\u003e\n \u003cli\u003eDisma, N.M. and M. Pittiruti, \u003cem\u003eEvidence based rationale for ultrasound guided vascular access in children\u003c/em\u003e, in \u003cem\u003eVascular Access in Neonates and Children\u003c/em\u003e. 2022, Springer. p. 25-29.\u003c/li\u003e\n \u003cli\u003eSpagnuolo, F. and T. Vacchiano, \u003cem\u003eUltrasound-guided cannulation of the brachiocephalic vein in newborns: a novel approach with a supraclavicular view for tip navigation and tip location.\u003c/em\u003e The Journal of Vascular Access, 2022. \u003cstrong\u003e23\u003c/strong\u003e(4): p. 515-523.\u003c/li\u003e\n \u003cli\u003eMghirbi, O., et al., \u003cem\u003eUltrasound-guided cannulation of the brachiocephalic vein in neonates: Feasibility and safety.\u003c/em\u003e The Journal of Vascular Access, 2024: p. 11297298251349037.\u003c/li\u003e\n \u003cli\u003eSe\u0026ccedil;ici, S., \u003cem\u003eLandmark guided internal jugular vein catheterization in infants undergoing congenital heart surgery.\u003c/em\u003e The European Research Journal, 2021. \u003cstrong\u003e7\u003c/strong\u003e(4): p. 375-379.\u003c/li\u003e\n \u003cli\u003eGurel, S., A. G\u0026ouml;zen, and M.S. Bektas, \u003cem\u003eCentral Subclavian Catheterization in Newborns: Single-Center Experience.\u003c/em\u003e Journal of Child Science, 2022. \u003cstrong\u003e12\u003c/strong\u003e(01): p. e5-e8.\u003c/li\u003e\n \u003cli\u003eFarhadi, E., et al., \u003cem\u003eComparison of open and ultrasound-guided placement of central venous catheter in children weighing less than five kilograms; a randomized clinical trial.\u003c/em\u003e Academic Radiology, 2023. \u003cstrong\u003e30\u003c/strong\u003e(7): p. 1419-1425.\u003c/li\u003e\n \u003cli\u003eMerchaoui, Z., et al., \u003cem\u003eUltrasound guided percutaneous catheterization of the brachiocephalic vein by small caliber catheter: An alternative to epicutaneo-caval catheter in newborn and premature infants.\u003c/em\u003e The Journal of Vascular Access, 2023. \u003cstrong\u003e24\u003c/strong\u003e(3): p. 487-491.\u003c/li\u003e\n \u003cli\u003eKarapinar, B. and A. Cura, \u003cem\u003eComplications of central venous catheterization in critically ill children.\u003c/em\u003e Pediatrics International, 2007. \u003cstrong\u003e49\u003c/strong\u003e(5): p. 593-599.\u003c/li\u003e\n \u003cli\u003eSangsari, R., et al., \u003cem\u003ePeripherally Inserted Central Catheter Tip Malposition in Neonates: A Comparison of Placement in the Head \u0026amp; Neck, Upper Extremity, and Lower Extremity.\u003c/em\u003e IJ Pediatrics, 2024. \u003cstrong\u003e34\u003c/strong\u003e(34).\u003c/li\u003e\n \u003cli\u003eJ\u0026oslash;rgensen, M.H., et al., \u003cem\u003eSafety of high‐volume plasmapheresis in children with acute liver failure.\u003c/em\u003e Journal of Pediatric Gastroenterology and Nutrition, 2021. \u003cstrong\u003e72\u003c/strong\u003e(6): p. 815-819.\u003c/li\u003e\n \u003cli\u003eCasado-Flores, J., et al., \u003cem\u003eSubclavian vein catheterization in critically ill children: analysis of 322 cannulations.\u003c/em\u003e Intensive care medicine, 1991. \u003cstrong\u003e17\u003c/strong\u003e(6): p. 350-354.\u003c/li\u003e\n \u003cli\u003eAraujo, C.C., M.C. Lima, and G.H. Falbo, \u003cem\u003ePercutaneous subclavian central venous catheterization in children and adolescents: success, complications and related factors.\u003c/em\u003e Jornal de pediatria, 2007. \u003cstrong\u003e83\u003c/strong\u003e: p. 64-70.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Central Venous Access, Open Jugular, Ultrasound -Guided Subclavian, Pediatric, Low-Weight","lastPublishedDoi":"10.21203/rs.3.rs-7933826/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7933826/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eThe necessity of this study stems from the lack of comparative evidence on the outcomes of central venous catheterization via the open internal jugular and ultrasound-guided subclavian approaches in low-weight pediatric patients. Its innovation lies in the simultaneous evaluation of both primary and secondary outcomes of these two techniques in this vulnerable population.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThis prospective randomized clinical trial at Mardani Azar Children\u0026rsquo;s Hospital (winter 2022\u0026ndash;2023) included 92 pediatric patients under five kilograms weight, randomly assigned to either open internal jugular or ultrasound-guided subclavian vein catheterization (46 per group). Procedural success and major complications\u0026mdash;such as pneumothorax, arterial cannulation, ectopic catheter placement, infection, and thrombosis\u0026mdash;were evaluated intraoperatively and during a two-weeks follow-up using imaging and clinical assessment.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe mean catheter placement time was significantly longer in the jugular group than in the subclavian group (41.19\u0026thinsp;\u0026plusmn;\u0026thinsp;13.8 vs. 33.15\u0026thinsp;\u0026plusmn;\u0026thinsp;12.12 minutes; P\u0026thinsp;=\u0026thinsp;0.04). No cases of pneumothorax, hemothorax, bleeding, arrhythmia, occlusion, infection, or death occurred in either group (P\u0026thinsp;=\u0026thinsp;1). Hematoma developed only in the jugular group (6 vs. 0; P\u0026thinsp;=\u0026thinsp;0.02), and all cases were associated with a procedure duration greater than 35 minutes (P\u0026thinsp;=\u0026thinsp;0.041). In the subclavian group, all failures (n\u0026thinsp;=\u0026thinsp;4) and upper limb edema (n\u0026thinsp;=\u0026thinsp;3) occurred exclusively in patients under 2.5 kg, with both outcomes significantly linked to lower body weight (P\u0026thinsp;=\u0026thinsp;0.03 and P\u0026thinsp;=\u0026thinsp;0.014, respectively). Other complications showed no significant differences between groups.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eBased on the findings from this study comparing two central venous catheterization techniques in children\u0026thinsp;\u0026lt;\u0026thinsp;5 kg, both methods were safe when performed by experienced teams, though complications occurred in each. For patients\u0026thinsp;\u0026gt;\u0026thinsp;2.5 kg, the ultrasound-guided subclavian approach is recommended due to its shorter procedure time and lower hematoma rate. Vein selection should depend on individual anatomy; if ultrasound-guided access fails or neck deformity limits jugular use, the subclavian route under ultrasound guidance is preferred. This procedure, however, requires skill and experience to prevent complications.\u003c/p\u003e\u003ch2\u003eTrial registration:\u003c/h2\u003e\u003cp\u003eThis clinical trial was registered in the Iranian Registry of Clinical Trials (IRCT) with the code IRCT20230901059317N1(Registration date: \u003cb\u003e2024-02-16)\u003c/b\u003e\u003c/p\u003e","manuscriptTitle":"Comparative Outcomes of Central Venous Access via Open Jugular and Ultrasound-Guided Subclavian Approaches in Low-Weight Pediatric Patients: A Study with Secondary Outcomes","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-13 08:32:28","doi":"10.21203/rs.3.rs-7933826/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-11-29T12:05:34+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-14T09:18:06+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-06T13:05:10+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-06T09:38:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"58441876733523786906320676585190461575","date":"2025-11-05T14:20:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"162489627010440658587476110268859179894","date":"2025-11-05T14:05:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"153617132655199999542777318805052523050","date":"2025-11-04T00:20:40+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-03T12:29:24+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-03T12:00:27+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-03T09:07:25+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Surgery","date":"2025-11-03T09:00:42+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7a55fe3b-01d7-4406-8ed0-4273f8fc5cc5","owner":[],"postedDate":"November 13th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-06T16:38:24+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-13 08:32:28","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7933826","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7933826","identity":"rs-7933826","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}