Complications of Central Venous Catheterization by Insertion Site

Parienti et al report in NEJM the finds of a trial regarding complications from central venous catheters depending on the insertion site. 

In this multicenter trial, they randomly assigned non-tunneled central venous catheterization in patients in the intensive care unit to the subclavian, jugular, or femoral veins.

The primary outcome measure was catheter-related bloodstream infection and symptomatic deep-vein thrombosis.

A total of 3471 catheters were inserted in 3027 patients. In the three-choice comparison, there were 8, 20, and 22 primary outcome events in the subclavian, jugular, and femoral groups, respectively (1.5, 3.6, and 4.6 per 1000 catheter-days; P=0.02). In pairwise comparisons, the risk of the primary outcome was significantly higher in the femoral group than in the subclavian group and in the jugular group than in the subclavian group, whereas the risk in the femoral group was similar to that in the jugular group. In the three-choice comparison, pneumothorax requiring chest-tube insertion occurred in 13 (1.5%) of the subclavian-vein insertions and 4 (0.5%) of the jugular-vein insertions.

The authors concluded that subclavian vein catheterization was associated with a lower risk of bloodstream infection and symptomatic thrombosis and a higher risk of pneumothorax than jugular vein or femoral vein catheterization.

N Engl J Med 2015; 373:1220-1229

Carotid Occlusion May Not Be Associated With High Risk For Stroke

Yang et al published on JAMA Neurology their retrospective analysis of patients who presented at two atherosclerosis clinics in Ontario with asymptomatic carotid artery stenoses that were followed for 20-years with carotid duplex scans.

Among the 3681 patients who had annual carotid ultrasound examinations, 316 (8.6%) were asymptomatic before an occlusion that occurred during observation period.

Of the new occlusions, 254 of 316 [80.4%] occurred before 2002, when medical therapy was less intensive; the frequency decreased by quartile of years (P < .001, χ2 test). Only 1 patient (0.3%) had a stroke at the time of the occlusion, and only 3 patients (0.9%) had an ipsilateral stroke during follow-up (all before 2005).

In Kaplan-Meier survival analyses, neither severity of stenosis nor contralateral occlusion predicted the risk of ipsilateral stroke or transient ischemic attack, death from stroke, or death from unknown cause at a mean follow-up of 2.56 years. In Cox proportional hazards regression analyses, only age (P = .02), sex (P = .01), and carotid plaque burden (P = .006) significantly predicted risk of those events.

The authors concluded that the risk of progression to carotid occlusion is well below the risk of carotid stenting or endarterectomy and has decreased markedly with more intensive medical therapy. Preventing carotid occlusion is not  a valid indication for intervention to prevent occlusion as the circle of Willis offers substantial protection.

JAMA Neurol. 2015.1843