Ultrasound-guided vs. Non-ultrasound-guided femoral artery puncture techniques: a comprehensive systematic review and meta-analysis

Abstract

Purpose: To compare the effectiveness of ultrasound-guided (US) versus non-US femoral artery puncture (FAP) methods, including fluoroscopy-guided (FL) and non-guided (NG) techniques.

Materials: This meta-analysis included 11 randomized controlled trials and 1 non-randomized retrospective study, comprising a total of 12 studies involving 5534 patients across diverse clinical settings. Studies varied in operator experience, institutional settings, and procedural protocols. Key outcomes assessed included complication rates, vessel access time, first-pass success rates, number of attempts, and the risk of accidental venipuncture.

Results: Analysis of the heterogeneous dataset showed that guided techniques were associated with reduced complication rates compared to NG methods (pooled odds ratio (OR): 0.45, 95% Confidence Interval (CI) 0.28-0.73). US guidance was associated with decreased vessel access time (mean difference: - 16.30 s, 95% CI - 29.83 to - 2.76), higher first-pass success rates (pooled OR: 3.54, 95% CI 2.36 to 5.30), and required fewer attempts compared to non-US techniques. US guidance also showed lower risk of inadvertent venipuncture (pooled OR: 0.22, 95% CI 0.14 to 0.34).

Conclusion: This meta-analysis suggests potential benefits of US femoral artery puncture techniques over non-US methods, while acknowledging significant heterogeneity across studies. The observed advantages in procedural outcomes varied across different clinical settings and operator experience levels. These findings provide setting for institutional decision-making regarding the implementation of guided puncture methods, considering factors such as operator expertise, resource availability, and specific patient populations.

Keywords: Body landmarks; Femoral artery puncture; Meta-analysis; Ultrasound guidance.

Fig. 1

Study flow diagram illustrating the article selection process for the meta-analysis. RCTs randomized controlled trials

Fig. 2

Risk of bias (RoB 2) assessment plot for the included randomized controlled trial studies. The assessment is based on five domains: D1 (randomization process), D2 (deviations from the intended interventions), D3 (missing outcome data), D4 (measurement of the outcome), and D5 (selection of the reported result). Each study is evaluated across these five domains, with a green circle indicating low risk of bias, a yellow circle indicating some concerns, and a red circle indicating a high risk of bias. The overall assessment for each study is provided in the rightmost column

Fig. 3

Risk estimates for complication rates. The forest plot presents the ORs and 95% CI for successful femoral artery puncture, comparing US and FL techniques against NG techniques. Each subgroup represents individual studies included in the meta-analysis. The diamonds indicate the pooled ORs and corresponding 95% CIs for both the overall comparison (bottom) and subgroup comparisons (US vs NUS and FL vs NG). An OR below 1 favors the guided technique. The solid vertical line represents the null value (OR = 1). Heterogeneity statistics (Chi², I²) and tests for overall effect (Z) are provided to assess the consistency and significance of the findings. M-H Mantel-Hoenszel, CI confidence interval

Fig. 4

Estimates for time to access the artery. The forest plot displays the mean difference and 95% CIs for vessel access time (in seconds), comparing US and non-US femoral artery puncture techniques. Each subgroup represents individual studies included in the meta-analysis. The diamonds represent the pooled mean difference and 95% CI for the overall comparison. A negative mean difference favors the US technique, indicating a shorter vessel access time. The solid vertical line represents the null value (mean difference = 0). Heterogeneity statistics (Tau², Chi², I²) and tests for the overall effect (Z) are provided to assess the consistency and significance of the findings. SD standard deviation, IV inverse variance method for meta-analysis, CI confidence interval

Fig. 5

Estimates for success rate at the first attempts. The forest plot displays the ORs and 95% CIs for the first-pass success rates of US femoral artery puncture techniques compared to non-US techniques from individual studies and the pooled estimate. Each study-specific OR is depicted by squares, with the size proportional to the study's weight in the meta-analysis. The horizontal lines represent the 95% CIs for each study, and the diamond represents the pooled OR and its 95% CI. An OR greater than 1 favors the US technique for achieving first-pass success. Heterogeneity statistics (Chi², I²) and tests for the overall effect (Z) are provided to assess the consistency and significance of the findings. M-H Mantel-Hoenszel, CI confidence interval, df degrees of freedom

Fig. 6

Estimates for number of attempts. The forest plot illustrates the meta-analysis of the number of attempts for femoral artery puncture, comparing US and non-US techniques. Each study-specific mean difference and its 95% CIs are represented by squares and horizontal lines, respectively. The diamond represents the pooled mean difference and its 95% CI. The study weights, based on the inverse variance method, are indicated by the size of the squares. Heterogeneity statistics (Chi², I²) and tests for the overall effect (Z) are provided to assess the consistency and significance of the findings. SD standard deviation, IV inverse variance method for meta-analysis, CI confidence interval, df degrees of freedom

Fig. 7

Risk estimates for venipuncture. The forest plot presents the meta-analysis of the risk of venipuncture during femoral artery puncture, comparing US and non-US techniques. Each square represents the OR of individual studies, with the size proportional to the study's weight in the meta-analysis. The horizontal lines represent the 95% CIs. The diamond indicates the pooled OR and its 95% CI. The solid vertical line at 1 represents no difference between the groups, with values to the left favoring the US group (lower risk) and values to the right favoring the NG group (higher risk). Heterogeneity statistics (Chi², I²) and tests for the overall effect (Z) are provided to assess the consistency and significance of the findings. M-H Mantel-Hoenszel, CI confidence interval, df degrees of freedom