Introduction
Central venous catheterization (CVC) is an essential procedure in modern anesthetic and critical care practice. It provides reliable vascular access for hemodynamic monitoring, administration of vasoactive drugs, fluid resuscitation, parenteral nutrition, chemotherapy, and long-term intravenous therapy. Although central venous access can be obtained through several anatomical sites, the internal jugular vein (IJV) remains one of the most frequently used approaches because of its predictable anatomy and relatively lower risk of pneumothorax compared with the subclavian route [1].
Traditionally, central venous catheterization has been performed using anatomical landmarks. However, landmark-guided techniques are associated with variable success rates and may result in complications such as arterial puncture, hematoma formation, pneumothorax, hemothorax, catheter malposition, and multiple puncture attempts. The introduction of ultrasound guidance has significantly improved the safety and effectiveness of central venous access by allowing real-time visualization of vascular anatomy and needle placement [2]. Consequently, ultrasound-guided central venous catheterization is now considered the standard of care in many institutions and is recommended by several international guidelines [3].
Numerous studies have demonstrated that ultrasound-guided internal jugular vein cannulation is associated with higher first-pass success rates, reduced procedure time, fewer needle passes, and lower complication rates compared with landmark-based techniques [4]. The ability to visualize the vein, surrounding structures, and needle trajectory in real time enables operators to perform the procedure with greater accuracy and confidence, thereby enhancing patient safety [5].
Despite the widespread use of the internal jugular vein approach, certain anatomical and technical limitations remain. Variations in vessel size, overlap between the carotid artery and internal jugular vein, obesity, previous catheterizations, neck deformities, and intravascular thrombosis may complicate cannulation and increase procedural difficulty. Therefore, alternative ultrasound-guided approaches have been explored to improve procedural success and reduce complications [6].
One such alternative is cannulation at the Pirogoff’s confluence, which represents the junction of the internal jugular vein, subclavian vein, and brachiocephalic vein. This anatomical region offers several potential advantages, including a larger venous diameter, improved sonographic visualization, reduced vessel collapsibility, and a wider target area for needle insertion. The larger caliber of the brachiocephalic vein and its confluence with major central veins may facilitate easier catheter placement and potentially improve first-attempt success rates [7].
Recent advances in ultrasound technology have enabled detailed visualization of the Pirogoff’s confluence and have renewed interest in this approach for central venous access. Studies evaluating ultrasound-guided brachiocephalic vein cannulation have reported favorable outcomes with high success rates and low complication profiles. Furthermore, the supraclavicular approach to the brachiocephalic vein has been shown to provide excellent ultrasound windows and favorable needle alignment during catheter insertion [8].
Comparative studies between internal jugular vein cannulation and brachiocephalic vein cannulation have demonstrated encouraging results. Several investigators have reported shorter access times, fewer needle redirections, and improved first-pass success rates with brachiocephalic vein access, while maintaining comparable safety profiles. However, findings across studies remain inconsistent, and evidence regarding the superiority of one site over another remains limited [9].
The efficacy of a central venous access technique is commonly assessed using parameters such as overall success rate, first-attempt success rate, number of puncture attempts, procedural duration, ease of cannulation, and incidence of mechanical complications. Evaluating these parameters is essential for identifying the optimal access site that maximizes procedural success while minimizing patient risk [10].
Although ultrasound-guided internal jugular vein cannulation remains a widely accepted technique, the growing evidence supporting cannulation at the Pirogoff’s confluence suggests that it may serve as a valuable alternative. Direct comparison of these two ultrasound-guided approaches may provide important insights into their relative efficacy and safety. Therefore, the present study was undertaken to compare the efficacy of ultrasound-guided central venous catheterization at the internal jugular vein and at the Pirogoff’s confluence in terms of success rate, first-pass success, procedural duration, number of attempts, and procedure-related complications.
Material and Methods
This prospective randomized comparative study was conducted in the Department of Anaesthesiology at a tertiary care teaching hospital after obtaining approval from the Institutional Ethics Committee. The study was carried out over a period of one year. Written informed consent was obtained from all participants or their legally authorized representatives before enrollment. The study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki.
A total of 150 adult patients requiring elective central venous catheterization for surgical or critical care indications were included in the study. Patients aged 18 years and above belonging to American Society of Anesthesiologists (ASA) physical status I, II, III, and IV were considered eligible. Patients with local infection at the insertion site, coagulopathy, thrombosis of the target vein, previous neck or clavicular surgery, severe anatomical deformity, superior vena cava syndrome, or refusal to participate were excluded from the study.
The enrolled patients were randomly allocated into two equal groups comprising 75 patients each using a computer-generated randomization sequence. Group I underwent ultrasound-guided central venous catheterization through the internal jugular vein. Group P underwent ultrasound-guided central venous catheterization through the Pirogoff’s confluence involving the junction of the internal jugular vein, subclavian vein, and brachiocephalic vein.
All procedures were performed under strict aseptic precautions by experienced anesthesiologists trained in ultrasound-guided vascular access. A high-frequency linear ultrasound probe was used to identify the target vessel and guide needle insertion in real time. After successful venous puncture, guidewire placement was confirmed sonographically whenever feasible, followed by catheter insertion using the Seldinger technique. Correct catheter placement was subsequently confirmed according to institutional protocol.
Demographic variables including age, gender, body mass index, ASA physical status, indication for catheterization, and side of catheter placement were recorded. The primary outcome measure was overall catheterization success rate. Secondary outcome measures included first-attempt success rate, number of puncture attempts, access time, total procedural duration, needle redirections, ease of cannulation, and incidence of complications.
Access time was defined as the interval between skin puncture and successful venous blood aspiration. Procedural duration was defined as the time from skin puncture to successful catheter placement. Complications assessed included arterial puncture, hematoma formation, pneumothorax, hemothorax, catheter malposition, guidewire-related difficulties, and failed catheterization.
All collected data were entered into Microsoft Excel and analyzed using Statistical Package for the Social Sciences (SPSS) software version 26.0. Continuous variables were expressed as mean ± standard deviation, whereas categorical variables were expressed as frequencies and percentages. Independent Student’s t-test was used for comparison of quantitative variables between groups. Chi-square test or Fisher’s exact test was used for comparison of qualitative variables as appropriate. A p-value of less than 0.05 was considered statistically significant.
Results
Table 1 compares the procedural characteristics between the Internal Jugular Vein (IJV) group and the Pirogoff’s Confluence group among 150 patients, with 75 patients in each group. The mean visualization time was significantly lower in the IJV group (0.82±0.21 min) compared to the Pirogoff group (1.16±0.35 min) (p=0.001). Similarly, access time was shorter in the IJV group (1.18±0.31 min) than in the Pirogoff group (1.54±0.48 min) (p=0.003). The mean time required for successful central venous catheterization was 2.68±0.62 min in the IJV group and 3.46±0.84 min in the Pirogoff group (p<0.001). Total procedural time was also significantly lower in the IJV group (12.08±1.36 min) compared to the Pirogoff group (13.21±1.52 min) (p=0.007). However, the mean catheter length inserted was significantly greater in the IJV group (13.41±0.88 cm) than in the Pirogoff group (12.74±0.76 cm) (p=0.002).
Table 2 demonstrates the comparison of mean arterial pressure and heart rate between the two study groups at different time intervals. Baseline mean arterial pressure was 89.6±12.4 mmHg in the IJV group and 91.1±11.8 mmHg in the Pirogoff group (p=0.421). Throughout the observation period from 0 to 20 minutes, no statistically significant differences were observed between the groups (p>0.05 at all intervals). Similarly, heart rate remained stable and comparable between the groups. Baseline heart rates were 78.9±13.8 bpm and 80.1±14.2 bpm in the IJV and Pirogoff groups respectively (p=0.618). These findings indicate that both approaches maintained comparable hemodynamic stability during and after catheterization.
Table 3 presents the comparison of the number of attempts and complications between the two groups. Successful cannulation on the first attempt was achieved in 68 patients (90.7%) in the IJV group and 65 patients (86.7%) in the Pirogoff group. Two attempts were required in 7 (9.3%) and 10 (13.3%) patients respectively. The difference was not statistically significant (p=0.441). Complications were observed in 3 patients (4.0%) in the IJV group and 5 patients (6.7%) in the Pirogoff group. Overall complication rates remained low and comparable between the groups (p=0.468), demonstrating the safety of both ultrasound-guided techniques.
| Variable | Group | Mean | SD | t-value | p-value |
| Time for Visualization (min) | IJV | 0.82 | 0.21 | 4.118 | 0.001* |
| Pirogoff | 1.16 | 0.35 | |||
| Access Time (min) | IJV | 1.18 | 0.31 | 3.856 | 0.003* |
| Pirogoff | 1.54 | 0.48 | |||
| Time to CVC (min) | IJV | 2.68 | 0.62 | 5.722 | <0.001* |
| Pirogoff | 3.46 | 0.84 | |||
| Total Time for Procedure (min) | IJV | 12.08 | 1.36 | 2.746 | 0.007* |
| Pirogoff | 13.21 | 1.52 | |||
| Length of Catheter Inserted (cm) | IJV | 13.41 | 0.88 | 3.184 | 0.002* |
| Pirogoff | 12.74 | 0.76 |
| Time Interval | Group | Mean Arterial Pressure (mmHg) Mean ± SD | p-value | Heart Rate (bpm) Mean ± SD | p-value |
| Baseline | IJV | 89.6 ± 12.4 | 0.421 | 78.9 ± 13.8 | 0.618 |
| Pirogoff | 91.1 ± 11.8 | 80.1 ± 14.2 | |||
| 0 min | IJV | 89.2 ± 11.5 | 0.587 | 78.4 ± 12.6 | 0.642 |
| Pirogoff | 90.3 ± 10.9 | 79.2 ± 13.1 | |||
| 5 min | IJV | 89.8 ± 10.8 | 0.736 | 77.8 ± 11.9 | 0.529 |
| Pirogoff | 90.5 ± 10.2 | 78.9 ± 12.5 | |||
| 10 min | IJV | 90.1 ± 9.8 | 0.689 | 76.8 ± 10.7 | 0.447 |
| Pirogoff | 89.7 ± 10.4 | 78.0 ± 11.6 | |||
| 15 min | IJV | 88.9 ± 8.9 | 0.592 | 75.6 ± 9.8 | 0.573 |
| Pirogoff | 89.4 ± 9.6 | 76.8 ± 10.9 | |||
| 20 min | IJV | 88.2 ± 8.4 | 0.488 | 74.8 ± 8.9 | 0.619 |
| Pirogoff | 89.1 ± 9.1 | 75.9 ± 9.8 |
| Variable | Category | IJV (n=75) | Pirogoff (n=75) | Total (n=150) | Chi-square | p-value |
| Number of Attempts | 1 Attempt | 68 (90.7%) | 65 (86.7%) | 133 (88.7%) | 0.592 | 0.441 |
| 2 Attempts | 7 (9.3%) | 10 (13.3%) | 17 (11.3%) | |||
| Complications | Absent | 72 (96.0%) | 70 (93.3%) | 142 (94.7%) | 0.526 | 0.468 |
| Present | 3 (4.0%) | 5 (6.7%) | 8 (5.3%) |
Discussion
The present study compared the efficacy of ultrasound-guided central venous catheterization performed through the Internal Jugular Vein (IJV) and the Pirogoff’s confluence in 150 patients. The findings demonstrated that the IJV approach was associated with significantly shorter visualization time, access time, time to successful catheterization, and overall procedural duration compared with the Pirogoff’s confluence approach. However, both techniques exhibited similar success rates, comparable hemodynamic stability, and low complication rates, confirming the safety and effectiveness of ultrasound guidance for central venous access.
In the present study, the mean visualization time was significantly lower in the IJV group (0.82±0.21 min) compared to the Pirogoff group (1.16±0.35 min). Similarly, access time and time to successful catheterization were significantly shorter in the IJV group. These findings suggest that the internal jugular vein offers easier sonographic identification and more rapid access because of its superficial location and consistent anatomical landmarks. Vinayak et al.,[11] compared ultrasound-guided brachiocephalic vein and internal jugular vein cannulation and reported that the internal jugular vein allowed faster localization and cannulation in a majority of patients. The authors attributed this advantage to the familiarity of clinicians with the IJV approach and its favorable anatomical position.
The total procedural duration was also significantly shorter in the IJV group than in the Pirogoff group. Although the Pirogoff’s confluence provides a larger vascular target due to the junction of the internal jugular, subclavian, and brachiocephalic veins, visualization of this deeper anatomical region often requires greater probe manipulation and operator expertise. Similar findings were reported by Rao et al.,[12], who observed that brachiocephalic vein cannulation required slightly longer preparation and imaging time despite demonstrating satisfactory success rates. Their study concluded that while the brachiocephalic route is feasible, the internal jugular vein remains technically simpler for routine clinical use.
The current study demonstrated comparable first-attempt success rates between the two groups. Successful cannulation on the first attempt was achieved in 90.7% of patients in the IJV group and 86.7% in the Pirogoff group, with no statistically significant difference. These findings indicate that both ultrasound-guided approaches are highly effective when performed by experienced operators. Kulkarni et al.,[13] similarly reported no significant difference in first-pass success rates between ultrasound-guided internal jugular vein and brachiocephalic vein catheterization. Their findings support the concept that ultrasound guidance minimizes anatomical uncertainties and contributes substantially to procedural success irrespective of the selected venous access site.
Complication rates in the present study were low in both groups, with complications observed in only 4.0% of patients undergoing IJV cannulation and 6.7% of those undergoing Pirogoff’s confluence cannulation. The difference was not statistically significant. These findings emphasize the safety of real-time ultrasound guidance in preventing arterial puncture, hematoma formation, catheter malposition, and other procedure-related complications. Khandelwal et al.,[14] reported comparable safety profiles between ultrasound-guided Pirogoff confluence cannulation and internal jugular vein cannulation, with both approaches demonstrating minimal mechanical complications. Their results corroborate the findings of the present investigation.
Hemodynamic stability was maintained throughout the procedure in both groups. Mean arterial pressure and heart rate remained comparable at baseline and throughout the observation period, with no statistically significant intergroup differences. These findings indicate that neither access technique adversely affected cardiovascular parameters. Gupta et al.,[15] also reported stable hemodynamic profiles during ultrasound-guided central venous catheterization at the Pirogoff confluence and the internal jugular vein. The authors concluded that both approaches are well tolerated and can be safely employed in patients requiring central venous access.
An additional observation of the present study was the significantly greater catheter length inserted in the IJV group compared with the Pirogoff group. This finding is anatomically expected because the catheter trajectory from the internal jugular vein to the superior vena cava generally requires a longer intravascular course than access through the venous confluence. Despite this difference, no adverse events related to catheter positioning were observed, further highlighting the effectiveness of ultrasound guidance in ensuring appropriate catheter placement.
Overall, the findings of the present study demonstrate that both ultrasound-guided internal jugular vein cannulation and Pirogoff’s confluence cannulation are effective and safe techniques for central venous access. However, the internal jugular vein approach offers advantages in terms of faster visualization, quicker access, and reduced procedural duration, while maintaining similar success and complication rates.
Conclusion
Ultrasound-guided central venous catheterization through both the Internal Jugular Vein and the Pirogoff’s confluence was found to be safe and effective. The Internal Jugular Vein approach demonstrated significantly shorter visualization time, access time, catheterization time, and overall procedural duration compared with the Pirogoff’s confluence approach. First-attempt success rates, hemodynamic parameters, and complication rates were comparable between the groups. Therefore, although both approaches can be successfully utilized under ultrasound guidance, the Internal Jugular Vein may remain the preferred access site because of its procedural efficiency and ease of cannulation.
Declarations
Availability of Data
All data are available from the corresponding author on reasonable request.
Conflict of interest
No! Conflict of interest is found elsewhere considering this work.
Source of Funding
There was no financial support concerning this work.
Acknowledgements
None