Ultrasound-Guided Central Venous Access: Is Landmark-Only Placement Now Outdated?

The Question Is No Longer Ultrasound Versus Tradition

A skilled clinician can still obtain central venous access by landmarks. That fact does not establish that landmark-only placement should remain a routine first-line choice. The more relevant question is whether it is reasonable to accept avoidable uncertainty about vessel position when the operator can directly assess the vein, follow the needle, and confirm the guidewire before dilation. [1-5]

For planned or urgent internal jugular cannulation in a setting with a functioning ultrasound machine and a trained operator, the evidence has moved beyond equipoise. Current data favor real-time ultrasound for both procedural success and important mechanical complications, and no evaluated internal jugular outcome in the 2026 guideline favored the landmark technique. [1]

The axillary/subclavian and femoral questions require more nuance. The direction of effect still favors ultrasound, but the number of randomized studies, certainty of evidence, operator experience, and technical approach differ by site. [1] A defensible policy therefore distinguishes among access sites while making dynamic ultrasound the institutional default whenever it is feasible.

What Counts as Ultrasound-Guided Access?

A machine in the room does not make a procedure ultrasound-guided. Modern guidance describes a sequence with at least three components:

1. Preprocedure assessment: Identify the vein and adjacent artery, assess vessel caliber and depth, look for thrombosis or anatomic variation, and select the safest practical site. [1,3,5]
2. Dynamic needle guidance: Use real-time imaging while advancing the needle, with repeated or continuous identification of the needle tip rather than watching only tissue movement. [2,3,5]
3. Guidewire confirmation before dilation: Demonstrate that the wire is intravascular in the intended vein, as far as the available window permits, before advancing a dilator or large-bore catheter. [1,2,4,5]

Static ultrasound used only to mark the skin is not equivalent to dynamic guidance. The Society of Hospital Medicine specifically recommends against static ultrasound alone for marking an insertion site and recommends real-time two-dimensional guidance for central venous catheter insertion. [5] The 2025 Association of Anaesthetists guideline similarly recommends an immediate scouting scan followed by real-time visualization of needle entry and proximal scanning of the guidewire before dilation. [2]

The Evidence Is Site-Specific

Access site	Comparative evidence summarized in 2026	Practical interpretation
Internal jugular	22 randomized studies informed the update. First-attempt success increased (RR 1.37; 95% CI 1.14-1.65), attempts decreased by a mean of 0.98, and accidental carotid puncture decreased (RR 0.27; 95% CI 0.19-0.38). [1]	Strongest case for abandoning landmark-only placement as the routine default.
Axillary/subclavian	Six randomized trials showed higher overall success (RR 1.14; 95% CI 1.06-1.23), higher first-attempt success (RR 1.32; 95% CI 1.14-1.54), and fewer arterial punctures (RR 0.17; 95% CI 0.07-0.45). [1]	The direction is favorable, but training, approach, and a smaller evidence base support a more conditional implementation strategy.
Femoral	One randomized trial with 110 participants supported higher overall success (RR 1.23; 95% CI 1.07-1.41) and first-attempt success (RR 1.57; 95% CI 1.20-2.04). [1]	Ultrasound is favored, but certainty is very low, and overstatement should be avoided.

Internal Jugular Access: The Landmark Default Is No Longer Defensible

Internal jugular catheterization has the clearest evidence base. The 2026 Polish Society of Anaesthesiology and Intensive Therapy guideline updated the older Cochrane evidence and identified 22 randomized studies, 20 of which evaluated real-time ultrasound. [1] Compared with landmark placement, ultrasound increased first-attempt success, reduced the number of attempts, and reduced accidental carotid puncture by approximately 73% on a relative scale. [1]

The pneumothorax estimate also favored ultrasound, but the confidence interval crossed no effect, so it should not be described as a statistically proven reduction in that analysis. [1] The certainty of evidence varied from very low to moderate, and the studies collectively had important risk-of-bias limitations. [1] Even with those limitations, the guideline strongly recommended real-time ultrasound over landmarks for internal jugular cannulation. [1]

This conclusion is not based on a single new trial. A 2015 Cochrane review had already included 35 studies with 5,108 participants and found fewer total complications, arterial punctures, attempts, and hematomas with two-dimensional ultrasound. [8] The 2026 update reinforces rather than reverses that longstanding direction of evidence. [1]

Axillary/Subclavian Access: The Evidence Is Stronger Than Its Reputation

Subclavian access has often been treated as the remaining stronghold of landmark technique because the vessel can be harder to visualize, pleural injury is a concern, and many clinicians were trained in a fixed infraclavicular approach. Contemporary evidence increasingly challenges that exception.

The 2026 guideline identified six randomized trials and found higher overall and first-attempt success, fewer attempts, and markedly fewer arterial punctures with real-time ultrasound. [1] Pneumothorax was uncommon, and the pooled confidence interval was wide, but the absolute counts favored ultrasound: 1 event among 368 ultrasound-guided procedures versus 13 among 384 landmark procedures. [1] The panel issued a weak recommendation rather than a strong one, reflecting evidence certainty and implementation demands rather than a signal that landmarks performed better. [1]

A 2026 randomized trial adds useful but limited detail. In 101 elective surgical patients, a microconvex in-plane ultrasound technique produced a lower composite procedural risk score than a landmark technique performed after an ultrasound prescan. [9] As-treated success was 86% versus 71%, arterial puncture occurred in 1.9% versus 12%, and one pneumothorax occurred in each group. [9] Total procedure time was about 5 minutes longer with the studied ultrasound workflow, and intention-to-treat success did not differ significantly. [9] The study was small, elective, technique-specific, and not sufficient by itself to establish a universal subclavian method. [9]

The practical lesson is not that every clinician who can place an ultrasound-guided internal jugular line is automatically competent at axillary/subclavian access. Institutions should teach and credential a reproducible ultrasound-guided approach rather than preserve landmark placement simply because training infrastructure is incomplete. [1-3]

Femoral Access: Favorable Direction, Low Certainty

The femoral evidence is substantially thinner. The 2026 guideline found only one randomized trial with 110 participants for the real-time ultrasound comparison. [1] Overall success, first-attempt success, and the number of attempts favored ultrasound, but all outcomes were rated very low certainty. [1] The arterial-puncture estimate also favored ultrasound, but the confidence interval crossed no effect. [1]

This is enough to support ultrasound as the preferred default when available, especially because the femoral vein and artery can overlap and imaging can identify thrombosis or variant anatomy. [1,3,5] It is not enough to claim the same level of evidentiary certainty that exists for internal jugular access.

What Major Guidance Says Now

Source	Position on ultrasound	Important qualification
Polish Society of Anaesthesiology and Intensive Therapy, 2026	Strong recommendation for internal jugular; weak recommendations for axillary/subclavian and femoral real-time ultrasound. [1]	Developed for critically ill adults in ICUs; application outside that population requires clinical judgment.
Association of Anaesthetists, 2025	Real-time ultrasound should be used for all central venous access and other applicable sites. [2]	Recommendation reflects widespread UK equipment access; landmark skills remain relevant when imaging is unavailable or unusable.
American Society of Echocardiography, 2025	Supports precannulation assessment, dynamic guidance, complication recognition, and competency-based training. [3]	Notes that the overall evidence quality remains weak in parts of the literature and that equipment and proficiency affect implementation.
American Society of Anesthesiologists, 2020	Use real-time ultrasound for internal jugular access; consider it for subclavian or femoral access when feasible. [4]	Preserves flexibility for emergencies and other clinical constraints.
Society of Hospital Medicine, 2019	Recommends dynamic two-dimensional ultrasound for central venous catheter insertion regardless of operator experience. [5]	Ultrasound must be paired with training, sterile technique, needle-tip visualization, and wire confirmation.
CDC catheter guidance	Use ultrasound when available to reduce attempts and mechanical complications, and restrict use to trained operators. [6]	Ultrasound is one component of insertion safety and infection prevention.

The wording is not identical, but the direction is consistent. No major current source reviewed for this article endorses landmark-only internal jugular placement as the preferred routine technique when dynamic ultrasound and a competent operator are available. [1-6]

What “Outdated” Should and Should Not Mean

In this context, outdated should mean that landmark-only placement is no longer the preferred routine workflow under ordinary, well-resourced conditions. It should not mean that an experienced operator can never use landmarks safely, that ultrasound eliminates complications, or that every landmark procedure establishes negligence.

Guidelines inform professional expectations, but they do not erase patient-specific judgment, emergency constraints, local resources, or operator capability. The 2026 ICU guideline explicitly places responsibility on the treating clinician to determine whether its recommendations fit the clinical context. [1] The safest conclusion is therefore procedural rather than legal: when dynamic ultrasound is available, usable, and supported by operator competence, choosing landmark-only internal jugular access as a routine first option requires a stronger justification than it once did.

When Landmark-Only Access May Still Be Defensible

A limited rescue role remains. Examples include:

• Immediate life threat when ultrasound would create a clinically meaningful delay: A true emergency may require the fastest feasible route in the hands of the available operator. [4,7]
• No functioning or immediately available ultrasound: Resource-poor settings, equipment failure, and austere environments may make dynamic guidance impossible. [2,7]
• Imaging is technically unusable: Extensive surgical or subcutaneous emphysema can obscure the sonographic window. [2,7]
• A highly selected prehospital scenario: A 2026 expert reply described landmark subclavian access as potentially important in expert hands for severe hypovolemic shock when peripheral and intraosseous access are inadequate or impossible, and ultrasound may delay insertion. [7]

These exceptions should not be expanded into a general defense of routine landmark practice. The same 2026 reply describes ultrasound-guided central access as the gold standard and advocates ultrasound for most axillary/subclavian insertions. [7] A contingency pathway is different from a coequal default.

Ultrasound Does Not Make a Central Line Safe by Itself

Ultrasound reduces one set of hazards, but it can introduce false reassurance if the rest of the procedure is weak. Safe placement still requires an appropriate indication, site and catheter selection, hand hygiene, maximal sterile barrier precautions, antisepsis, sterile probe protection, guidewire control, catheter-position confirmation, and prompt removal when the device is no longer needed. [2,4-6]

The sterile-gel requirement deserves explicit attention. In May 2025, CDC advised using only single-use ultrasound gel labeled sterile for percutaneous procedures, including central and peripheral intravenous catheter placement. [10] A product described only as bacteriostatic or containing a preservative should be treated as nonsterile unless the label specifically states that it is sterile. [10]

A 2024 meta-analysis of 12 studies and 5,092 central venous catheter procedures found fewer composite catheter-related infections with ultrasound than with landmark placement (RR 0.68; 95% CI 0.53-0.88). [11] The randomized-trial subgroup also favored ultrasound. [11] That finding is encouraging, but it combines several infection definitions and includes randomized and nonrandomized studies, so it should not be interpreted as proof that ultrasound independently prevents bloodstream infection. [11] The plausible benefits of fewer punctures and shorter tissue manipulation do not replace aseptic technique or a central-line bundle. [5,11,12]

Ultrasound guidance also does not settle every postplacement question. The 2026 ICU guideline did not recommend ultrasound as a universal replacement for chest radiography in routine assessment of catheter position and complications because certainty was very low. [1] Institutions should therefore separate the insertion-guidance standard from their protocol for final catheter and tip confirmation.

Training and Policy Implications

A policy that merely requires an ultrasound machine in the room is too weak. A modern central-access program should define competency in preprocedure scanning, vessel and artery identification, needle-tip tracking, guidewire confirmation, sterile probe and gel use, recognition of complications, and site-specific technique. [1-5,10]

Institutions should also ensure that equipment is accessible at the point of care, not locked in another service or available only after a delay. The ASE guideline notes that equipment availability and clinical proficiency may influence whether ultrasound becomes the practical standard more than additional efficacy studies will. [3]

Landmark anatomy should still be taught as rescue knowledge. It should not be taught as a routine equivalent when the same trainee is expected to practice in a setting with functioning ultrasound. For axillary/subclavian access in particular, supervised training and credentialing are necessary because the imaging plane, needle trajectory, pleural relationship, and wire visualization differ from internal jugular access. [1-3]

A reasonable quality program can track first-pass success, total attempts, arterial puncture, pneumothorax, hematoma, failed access, crossover to another site or operator, use of sterile gel, and documented guidewire confirmation. These data can identify whether an ultrasound mandate is producing genuine competence or only nominal compliance.

Limitations of the Evidence

The literature does not support a single undifferentiated claim for every central venous site. Internal jugular evidence is the most mature, axillary/subclavian evidence is smaller and technique-dependent, and femoral evidence is sparse. [1,8,9] Many studies predate current devices and training systems, use different definitions of procedural time and success, and include operators with varying experience. [1,3,8,9]

Rare complications such as pneumothorax produce wide confidence intervals even when absolute event counts favor ultrasound. [1] Infection analyses combine heterogeneous outcomes and cannot fully separate the effect of ultrasound from operator experience and aseptic practice. [11] Cost-effectiveness, maintenance of rescue landmark skills, and implementation in austere or prehospital environments remain incompletely studied. [1-3,7]

These limitations justify precise language. They do not restore equipoise for routine internal jugular placement in a well-resourced setting.

References

1. Zawadka M, Czarnik T, Gawda R, et al. Central venous cannulation in critically ill patients: guidelines of the Polish Society of Anaesthesiology and Intensive Therapy. Anaesthesiol Intensive Ther. 2026;58(1):84-105. DOI. PMID: 42246225. PubMed.
2. Johnston AJ, Simpson MJ, McCormack V, et al. Association of Anaesthetists guidelines: safe vascular access 2025. Anaesthesia. 2025;80(11):1381-1396. DOI. PMID: 40958714. PubMed.
3. Vegas A, Wells B, Braum P, et al. Guidelines for Performing Ultrasound-Guided Vascular Cannulation: Recommendations of the American Society of Echocardiography. J Am Soc Echocardiogr. 2025;38(2):57-91. DOI. PMID: 39909653. PubMed.
4. American Society of Anesthesiologists Task Force on Central Venous Access. Practice Guidelines for Central Venous Access 2020: An Updated Report by the American Society of Anesthesiologists Task Force on Central Venous Access. Anesthesiology. 2020;132(1):8-43. DOI. PMID: 31821240. PubMed.
5. Franco-Sadud R, Schnobrich D, Mathews BK, et al. Recommendations on the Use of Ultrasound Guidance for Central and Peripheral Vascular Access in Adults: A Position Statement of the Society of Hospital Medicine. J Hosp Med. 2019;14(9):E1-E22. DOI. PMID: 31561287. PMCID: PMC10193861. PubMed. PMC.
6. Centers for Disease Control and Prevention. Background Information: Strategies for Prevention of Catheter-Related Infections in Adult and Pediatric Patients. Updated April 12, 2024. Accessed August 20, 2026. CDC guidance.
7. Johnston AJ, Simpson M. Real-time ultrasound guidance for central venous access: a reply. Anaesthesia. Published online April 28, 2026. DOI. PMID: 42046863. PubMed.
8. Brass P, Hellmich M, Kolodziej L, Schick G, Smith AF. Ultrasound guidance versus anatomical landmarks for internal jugular vein catheterization. Cochrane Database Syst Rev. 2015;1(1):CD006962. DOI. PMID: 25575244. PMCID: PMC6517109. PubMed. PMC.
9. Conrad D, Schneider SO, Beller S, et al. Ultrasound-Guided In-Plane Subclavian Vein Puncture versus Prior Ultrasound and Landmark Technique: A Randomized Controlled Trial. Anesth Analg. 2026;142(5):857-865. DOI. PMID: 41980265. PMCID: PMC13048324. PubMed. PMC.
10. Centers for Disease Control and Prevention. Alert: Use Only Sterile Ultrasound Gel for Percutaneous Procedures. May 13, 2025. Accessed August 20, 2026. CDC alert.
11. Boulet N, Pensier J, Occean BV, et al. Central venous catheter-related infections: a systematic review, meta-analysis, trial sequential analysis and meta-regression comparing ultrasound guidance and landmark technique for insertion. Crit Care. 2024;28(1):378. DOI. PMID: 39563416. PMCID: PMC11577744. PubMed. PMC.
12. World Health Organization. Guidelines for the prevention of bloodstream infections and other infections associated with the use of intravascular catheters: part 2: central venous catheters. May 28, 2026. ISBN 978-92-4-012180-5. Accessed August 20, 2026. WHO publication.