Article, Ultrasound

The effect of vessel depth, diameter, and location on ultrasound-guided peripheral intravenous catheter longevity

Unlabelled imagevessel depth, diameter, an”>American Journal of Emergency Medicine (2012) 30, 1134-1140

Original Contribution

The effect of vessel depth, diameter, and location on ultrasound-guided peripheral intravenous catheter longevity?

J. Matthew Fields MD a,?, Anthony J. Dean MD b, Raleigh W. Todman MD b, Arthur K. Au MD a, Kenton L. Anderson MD b, Bon S. Ku MD, MPP a,

Jesse M. Pines MD, MSCE c, Nova L. Panebianco MD, MPH b

aDepartment of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA bDepartment of Emergency Medicine, University of Pennsylvania, Philadelphia, PA cDepartment of Emergency Medicine, George Washington University, Washington, DC

Received 7 July 2011; revised 29 July 2011; accepted 30 July 2011


Introduction: Ultrasound-guided peripheral intravenous catheters (USGPIVs) have been observed to have poor durability. The current study sets out to determine whether vessel characteristics (depth, diameter, and location) predict USGPIV longevity.

Methods: A secondary analysis was performed on a prospectively gathered database of patients who underwent USGPIV placement in an urban, tertiary care emergency department. All patients in the database had a 20-gauge, 48-mm-long catheter placed under ultrasound guidance. The time and reason for USGPIV removal were extracted by retrospective chart review. A Kaplan-Meier survival analysis was performed.

Results: After 48 hours from USGPIV placement, 32% (48/151) had failed prematurely, 24% (36/151) had been removed for routine reasons, and 44% (67/151) remained in working condition yielding a survival probability of 0.63 (95% confidence interval [CI], 0.53-0.70). Survival probability was perfect (1.00) when placed in shallow vessels (b0.4 cm), moderate (0.62; 95% CI, 0.51-0.71) for intermediate vessels (0.40-1.19 cm), and poor (0.29; 95% CI, 0.11-0.51) for deep vessels (>=1.2 cm); P b .0001. Intravenous survival probability was higher when placed in the antecubital fossa or forearm locations (0.83; 95% CI, 0.69-0.91) and lower in the brachial region (0.50; 95% CI, 0.38-0.61); P = .0002. The impact of vessel depth and location was significant after 3 hours and 18 hours, respectively. Vessel diameter did not affect USGPIV longevity.

Conclusion: Cannulation of deep and proximal vessels is associated with poor USGPIV survival. Careful selection of target vessels may help improve success of USGPIV placement and durability.

(C) 2012

? Previously presented as a Poster Presentation at the American College of Emergency Physicians Scientific Assembly October 2010, Las Vegas.

J. Matthew Fields, Raleigh W. Todman, Kenton L. Anderson, Nova L. Panebianco, and Anthony J. Dean. “229: Early Failure of Ultrasonography-Guided Peripheral Intravenous Catheters In the Emergency Department: It’s Not Just About Getting the IV – It’s About Keeping It.” Annals of Emergency Medicine 56, no. 3 (2010): S75-S76.

* Corresponding author.

E-mail address: [email protected] (J.M. Fields).

0735-6757/$ – see front matter (C) 2012 doi:10.1016/j.ajem.2011.07.027



Patients with difficult intravenous access (DIVA) present an ongoing challenge to providing emergency care and resuscitation. Of the 116.8 million emergency department (ED) visits in 2007 in the United States, 27% required intravenous catheter placement [1]. In many cases, failure to obtain peripheral IV access necessitates central venous cannulation, which introduces an increased risk of immediate and delayed complications secondary to a more invasive procedure and incurs increased use of departmental resources [2]. Extrajugular vein cannulation is an alternative approach but is obtainable in less than 50% of patients and usually necessitates the involvement of a physician [3]. This approach also usually requires the patient to tolerate supine or Trendelenburg positioning, which may be difficult for many patients.

Bedside ultrasound provides an alternative method of obtaining venous access when traditional landmark methods fail [4,5]. However, ultrasound-guided peripheral IVs (USGPIVs) have a failure rate of up to 8% in the first hour after placement and 47% within the first 24 hours after placement [4,6,7]. This is much higher than traditionally placed IVs, which have reported Failure rates of only 6% to 32% after 3 days [8,9]. Dislodgement of an IV has the potential to threaten patient safety by interrupting delivery of medications and fluids and putting patients at risk for extravasation that can lead to ischemia and/or tissue necrosis. There are limited data regarding the reasons for the higher rate of failure for IVs placed under ultrasound guidance. One possible explanation is that ultrasound provides the ability to access vessels that are deeper and smaller than those visible or palpable on physical examination. In addition, USGPIVs are often placed in different locations. In 1 study comparing the 2 techniques, 74% of USGPIVs were placed in the basilic or brachial vein, whereas 86% of traditionally placed IVs were placed in the forearm, hand, or antecubital fossa [10]. Catheters that have to traverse through more subcutaneous tissue or are in atypical loca- tions may be more likely to kink or dislodge suggesting the hypothesis that IV durability is affected by the character- istics of the vessel being cannulated. By analyzing the outcomes of IVs placed under ultrasound guidance, the current study sets out to determine the influence of vessel

depth, diameter, and location on IV longevity.


Study design

This study used a previously gathered database of DIVA patients who underwent USGPIV placement in the ED.

This database was gathered prospectively and included images and measurements of the target vessel’s depth, diameter, and location. The original analysis of this USGPIV database examined the relation between vessel depth and diameter on success of USGPIV placement and has been reported in the literature [11]. For the current study, an additional retrospective chart review was performed on patients in the database to determine the outcome and survival time of the USGPIVs. The institution internal review board approved the study, and written informed consent was obtained for all patients.

Study setting and population

Patients in this database were included in the current study if they had DIVA (defined as any patient with 2 failed peripheral IV attempts or a history of DIVA with the inability to visualize or palpate veins on physical examination) and underwent successful USGPIV placement by 1 of 4 study sonographers from December 2007 to May 2008. The setting was an urban tertiary care university ED with a 4-year emergency medicine residency program and an emergency ultrasound fellowship. All emergency medicine residents complete a 4-week ultrasound course during the second post- graduate year (PGY) during which the requirements for emergency ultrasound, as recommended by the American College of Emergency Physicians (ACEP) 2001 guidelines, are met [12]. The USGPIVs were placed by 2 PGY-2 residents, 1 PGY-3 resident, and an ultrasound fellow, all of whom had met the above ACEP guidelines as well as demonstrating successful placement of at least 10 USGPIVs.

Study protocol

Patients in the database underwent USGPIV placement with the following protocol. A tourniquet was applied to the upper extremity, which was then scanned for a target vessel using a Sonosite Micromaxx (Sonosite, Inc, Bothell, WA) with a high-frequency L38/13-6 MHz linear array transducer. Upon identification of a target vessel, the sonologist obtained a transverse image of the vessel with measurement of the vessel depth (distance from the skin surface to the near wall of vessel) and diameter (distance from middle of near wall to middle of far wall). The location of the vessel was documented on a diagram of the upper extremity. Sterilization of the overlying skin was standardized with chlorhexidine swab and use of a sterile sheath. Only 20-gauge, 48-mm-long (Angiocath Auto- guard; BD Medical Systems, Sandy, UT) catheters were used for USGPIV placement.

The sonologist attempted to place the catheter using the single-operator technique visualizing that the needle enters the vein using real-time dynamic scanning. The use of transverse and/or longitudinal plane was based on sonologist preference. Successful IV placement was defined as

aspiration of 5 mL of blood and the ability to flush the line without resistance. The depth, diameter, and location of all USGPIV attempts were recorded. In addition, background demographic, historical, and physical examination informa- tion was recorded for each patient.

The final outcome of each USGPIV was determined by a retrospective chart review. Patients were excluded if an USGPIV was unable to be established as per the above protocol or if lack of charting documentation prevented an accurate estimation of IV removal. In the study institution, a dedicated IV tracking form is used to document the status of all peripheral IVs on a continuous basis. Hospital policy mandates thrice-daily evaluation and documentation on this form of each IV access point on every patient, a record of the time of and reasons for IV removal, and any associated complications. Two blinded independent study personnel reviewed all charts, and the time and reason for IV removal were extracted from the IV tracking forms. If there was a disagreement between the 2 reviewers on the time of IV removal or on the reason for IV removal, a third reviewer examined the chart. Patients were excluded if there was a failure of a consensus of at least 2 of the 3 reviewers on the time or outcome of the IV. The reviewers followed the successfully placed USGPIVs for 48 hours or up to the point of IV removal, whichever came first. Failures were considered IVs that infiltrated, dislodged, stopped working, or were discontinued prematurely for any reason. The IVs that were removed for routine reasons such as lack of a need for ongoing IV access or patient discharge were not counted as failures.

Statistical analysis

Descriptive statistics were performed on patient charac- teristics for patients with failed vs nonfailed USGPIVs. Dichotomous data are presented as percentages. Continuous variables were categorized into logical groups for analysis. Vessel depth was divided into 3 zones: shallow (b0.4 cm), intermediate (0.4-1.19 cm), and deep (>=1.2 cm). Intravenous diameter was divided into 4 groups (b0.3, 0.3-0.39, 0.4-0.49, and >=0.5 cm). Vessel location was divided into proximal (brachial region) and distal (antecubital fossa, forearm, or hand veins). The Fisher exact test and ?2 test were used for comparisons of categorical variables, as appropriate. Follow- up began at the time and date of successful USGPIV placement and ended at the time and date of documented USGPIV failure or removal. To account for patient censoring (IVs that were removed for routine reasons such as patient discharge before the end of the 48-hour follow-up period), USGPIV longevity was analyzed using a Kaplan-Meier survival algorithm. Sample size was determined using the log-rank Freedman method to compare 2 survival functions. Based on previous data, 50% to 60% of USGPIVs fail at 48 hours. At least 92 patients were required to detect a 15% difference in survival for a given covariate assuming an ? of .05 and a power of 0.80.

Univariate analysis was performed on vessel characteris- tics (depth, diameter, and location) using the log-rank test of equality. Significant predictors in the univariate analysis (P b

.05) were included in a Cox proportional hazards regression analysis. This multivariate model checked for possible interactions between variables. Proportionality of the model was checked by visual inspection of the graphed Schoenfield residuals and goodness of fit was checked using Cox-Snell residuals. Stata 11 was used for the analysis (StataCorp, College Station, TX).


There were 183 patients in the database of which 18 patients were excluded for failure to successfully establish an USGPIV and 14 patients were excluded due to lack of sufficient documentation (12) or reviewer disagreement on IV outcome (2), yielding a total of 151 patients for analysis. The mean age of the patients was 53 years (SD, +-18 years). Ninety-six patients (64%) were female, and 115 (76.7%) were African American. Twenty-two USGPIVs (15%) were placed in shallow (b0.4 cm) vessels, 106 (70%) were placed in intermediate vessels (0.4-1.19 cm), and 23 (15%) were placed in deep vessels (>=1.2 cm). There were 22 USGPIVs (15%) placed in vessels with a diameter of less than 3 mm,

55 USGPIVs (36%) placed in vessels of 3 to 3.9 mm,

46 USGPIVs (30%) placed in vessels of 4 to 4.9 mm, and 28 USGPIVs (19%) placed in vessels of 5 mm or more. There were 95 USGPIVs (63%) placed proximally in the brachial region, and 56 (37%) placed distally in the antecubital fossa or forearm veins. No USGPIVs were placed in the wrist or hand.

After 48 hours, 48 USGPIVs (32%) had failed because of IV infiltration, dislodgement, or patient discomfort. Thirty- six USGPIVs (24%) had been removed for routine reasons, such as patient discharge or no further need for IV access, and the remaining 67 USGPIVs (44%) were still in place and without incident. Of the 48 USGPIV failures, 20 IVs (42%) infiltrated, 11 (23%) dislodged, 16 (33%) were not flushing, and 1 IV (2%) was removed because of patient discomfort. There were no significant differences in the patient characteristics of IVs that failed vs IVs that did not fail within 48 hours (Table 1).

Survival analysis

The Kaplan-Meier survival analysis yielded an USGPIV survival probability of 0.63 (95% confidence interval [CI] 0.53-0.70, Fig. 1) at 48 hours. Analysis of vessel characteristics using the log-rank test for equality revealed that vessel depth, location, and diameter each potentially had a significant association with IV longevity. When placed in the Cox multivariate regression model and checking for interactions between variables, both vessel depth and

Surviving a





n = 103

n = 48

Age (y)



20 (19.4)

11 (22.9)


39 (37.9)

10 (20.8)


27 (26.2)

16 (33.3)


17 (16.5)

11 (22.9)


49 (60.5)

48 (68.6)




African American

82 (79.6)

34 (70.8)


19 (18.5)

11 (22.9)

Obese (BMI, N30kg/m2)

35 (34.0)

19 (39.6)


History of DIVA

89 (86.4)

40 (83.3)


History of IVDA

20 (19.4)

4 (8.3)


History of dialysis

18 (17.5)

5 (10.4)


location were found to each be independently and signifi- cantly associated with USGPIV longevity; however, vessel diameter was not.

Table 1 Patient characteristics of patients with surviving vs failed USGPIVs

BMI indicates body mass index; IVDA, intravenous drug abuse.

a Surviving USGPIVs includes both USGPIVs in working condition at 48 hours or USGPIVs removed before 48 hours for routine reasons (patient discharge or lack of a further need for intravenous access).

Vessel depth

Ultrasound-guided peripheral IV survival probability was excellent (1.00) for shallow vessels (b0.4 cm, n = 22), moderate (0.62; 95% CI, 0.51-0.71) for intermediate vessels

(0.41-1.19 cm, n = 106), and poor (0.29; 95% CI, 0.11-51)

for deep vessels (>=1.2 cm, n = 23); P b .0001. Shallow and deep survival curves became significantly different as early as 3 hours after placement, and all 3 zones were significantly

Fig. 1 The USGPIV survival probability over time.

Fig. 2 A, The USGPIV survival by vessel depth. B, The USGPIV survival by vessel location.

different from each other from 12 hours onwards (Fig. 2A; Table 2).

Vessel location

Ultrasound-guided peripheral IV placement in the ante- cubital fossa or forearm was associated with improved survival probability when compared with more proximal placement in the region of the brachial or basilic veins (Fig. 2B; Table 2). The survival curves for vessel location became significantly different at 18 hours with a survival probability of 0.93 (95% CI, 0.82-0.97) for distal vessels vs

0.71 (95% CI, 0.60-0.80) for proximal vessels.

Multivariate model

In the Cox regression analysis, depth and location were each independently associated with IV longevity. For each increase of 0.2 cm in vessel depth, the odds of an IV failing within 48 hours increases by a hazard ratio of 1.36 (1.15- 1.61). Placement of an IV in the brachial region vs the

3 h

6 h

12 h

18 h

24 h

48 h

USGPIV outcomes

Working 147






Failed 3






Censored a 1






USGPIV survival probabilities b

All (n = 151) 0.98 (0.93-0.99)

0.95 (0.91-0.98)

0.84 (0.78-0.90)

0.79 (0.72-0.85)

0.76 (0.68-0.82)

0.63 (0.53-0.70)


b0.4 cm (n = 22) 1.00






0.4-1.19 cm (n = 106) 0.99 (0.94-1.00)

0.97 (0.92-0.99)

0.89 (0.82-0.94)

0.83 (0.74-0.89)

0.79 (0.70-0.86)

0.62 (0.51-0.71)

>=1.2 cm (n = 23) 0.91 (0.68-0.98)

0.82 (0.59-0.93)

0.49 (0.27-0.68)

0.43 (0.21-0.63)

0.37 (0.16-0.57)

0.29 (0.11-0.51)


Distal (n = 56) 1.00

0.96 (0.87-0.99)

0.93 (0.82-0.97)

0.93 (0.82-0.97)

0.93 (0.82-0.97)

0.83 (0.69-0.91)

Proximal (n = 95) 0.97 (0.90-0.99)

0.95 (0.88-0.98)

0.80 (0.70-0.87)

0.71 (0.60-0.80)

0.66 (0.54-0.75)

0.50 (0.38-0.61)

a Censored IVs are IVs that are removed for routine reasons (patient discharge or no further indication for intravenous access) and not due to IV failure.

b Survival probabilities represent the likelihood of IV survival to specified times.

Table 2 Outcomes and Kaplan-Meier survival probabilities (95% CI) of USGPIVs at varioUS times by vessel depth and location

Fig. 3 Examples of calculated USGPIV survival curves for vessels at given depths and location.

forearm or antecubital fossa increases the likelihood of failure by a hazard ratio of 2.76 (1.25-6.09). The multivar- iable model satisfied criteria for proportionality, and Cox- Snell residuals did not suggest a lack of goodness of fit for the model (P = .17). Using these Hazard ratios allows us to create a model to predict the survival curve for a given vessel depth and location. Examples of predicted survival curves for various permutations of vessel depth and location using this model are demonstrated (Fig. 3).


The aim of this study was to determine the effect of vessel parameters on the survival of USGPIVs. Although longevity of USGPIVs has been evaluated in other studies, this is the first study to examine the relationship of vessel character- istics and USGPIV survival [7]. The study found that vessel

depth and location were both predictive of early failure of USGPIVs. The vessel characteristic that was most strongly associated with failure was depth from skin surface, and this effect seemed to occur more rapidly when compared with other vessel characteristics. As early as 3 hours, USGPIVs placed in shallow vessels (b0.4 cm) had significantly better survival than those placed in deep vessels (>=1.2 cm). By 12 hours, over half of USGPIVs in deep vessels fail. Vessel location had a delayed but also independently significant effect on IV survival. Within 18 hours of placement, USGPIVs placed in the antecubital fossa or forearm had better survival compared with those placed in the brachial or basilic veins.

Two studies have shown that successful USGPIV placement is influenced by vessel diameter and depth [11,13]. The current study shows that after successful cannulation, the continued survival of the IV is also influenced by depth and, in addition, by IV location. Vessel diameter did not affect catheter survival after successful placement. Ideally, the sonologist would be able to select the vein with the greatest likelihood of both successful placement and longevity from a number of possible choices. However, when the choice is limited, as is often the case in patients with DIVA, knowledge of these relationships can aid the sonographer in choosing the optimal vessel for success and durability. When no suitable vessels exist, the sonographer can opt to select a different method of IV access (midline catheter, intraosseus line, or central venous cannulation) and not subject the patient to unnecessary IV sticks. In the case where an IV is needed for only a brief period, depth should be the main consideration. When using a 48-mm catheter, vessels of 1.2 cm ore more should be avoided altogether because they have a high immediate failure rate. When an IV is needed for a longer period (>=18 hours), the sonographer should additionally consider the importance of vessel location attempting to avoid vessels in the brachial region.

To our knowledge, there are no studies specifically investigating the basis of the association between deeper and proximal veins and poor IV survival, although the finding is unlikely to surprise emergency physicians familiar with the challenges of maintaining IV access in this patient population. With deeper vessels, a shorter portion of catheter tip ends up in the vessel and is more easily dislodged. In addition, with a constant catheter length, deeper vessels require inserting the catheter at a steeper angle. This has several theoretical adverse consequences. First, it makes it increasingly likely that the tip of the introducer needle pierces the back wall of the vessel before full introduction of the plastic catheter, resulting in damage to the vessel (predisposing to both leakage and thrombosis). Second, if the back wall of the vessel is not punctured, there is an increased risk of the catheter tip getting caught up on it or traumatizing the endothelium as it is advanced. Third, the sharp angle between the subcutaneous path of the catheter and the vessel often results in kinking when it changes its direction to conform to the vessel. This severely limits flow of intravenous fluids as well as being another potential source of trauma and/or thrombosis in the vessel.

With respect to location, the subcutaneous fat of the arm is often thicker and looser than that in the antecubital fossa or forearm [14]. This makes it incrementally vulnerable to failure, both due to the reasons discussed above and also due to the instability, mobility, and mass of the surrounding loose adipose tissue. This may be exacerbated by the tendency to compress the subcutaneous tissue to facilitate cannulation. When these tissues are released and reexpand after successful placement of the USGPIV, there is distortion of the catheter track with the potential for dislodgement or kinking. The mobility of the Shoulder joint as well as the location of the basilic and brachial veins on the medial side of the arm may also render these sites at greater risk for mechanical dislodgement. The only study to cast light on this issue, the one by Mills et al [6], supports the notion that short catheter length may be a cardinal flaw in deeper vessels. In that study, a standard-length catheter was used to cannulate the vein, but this was immediately followed by placement of a 15-cm-long catheter over a guide wire. The only catheter of 24 subsequently to fail (median duration of catheter survival 26 hours) did so after 15 minutes. This study used proximal veins exclusively, making these findings particularly striking compared with ours in which 66% of patients in this group had lost their IVs within 24 hours. Notably, the findings of Dargin et al [7], using a 63.5-mm catheter, were very similar to ours. Further studies are needed to identify the minimal length and optimal catheter type for improved IV longevity in these deeper peripheral veins.


Potential bias may have occurred as a result of the outcome variable (IV longevity) being obtained by retro-

spective chart review. The reliability of this outcome is contingent on rapid realization of IV failure and clear documentation of the event by hospital personnel. Although there were some charts that lacked clear documentation of IV outcome (12/183), there was little disagreement between the

2 reviewers (2/183). Furthermore, in spite of the strict hospital policies regarding documentation about IV access sites, it is possible that failed catheters were documented as “removed” because they were no longer needed, another was easily obtained, or to avoid the appearance of an adverse event. In addition, it is in the nature of an IV failure that it can only be detected after it has occurred, and IV failures are rarely detected immediately. All these factors would lead to bias toward the appearance of artifactually increased longevity. Stated more simply: our study necessarily under- estimated the failure rate of the USGPIVs.

Some factors that may have affected the lifespan of the IVs were not collected. These include the nature of the infusions running through the IV, how often the IV was accessed, movement of the extremity, or whether any fixation device such as an arm board was used. In addition, there was no standardization to the method for which the IV was secured. In our institution, peripheral IVs are routinely secured by use of a Tegaderm, and other commercially available fixation devices such as arm boards are rarely used. It is possible that USGPIV longevity could be improved by postprocedural methods; however, this was not assessed in this study.

The generalizability of the study may be limited because this was a single-center study, and with a relatively small cohort of sonologists obtaining data, it is likely that their skills with USGPIV cannulation are superior to the average among emergency physicians. However, the 1-hour 10% early IV failure rate seen in our study is similar to failure rates documented in other studies [4,7]. The early USGPIV failure depth of 1.2 cm found in our study was based on using a catheter length of 48 mm. As noted above, it is likely that altering either the catheter length or the angle of approach would affect the depths at which USGPIV longevity is compromised. In addition, only 1 catheter gauge was used (20-gauge). This variable was controlled in the database to assess the relationship of other variables on USGPIV success rates. Interestingly, a study by Catney et al [8] found that 18- gauge IVs were more durable than 20- or 22-gauge IVs, suggesting that larger diameter thicker catheters may be less susceptible to IV kinking and failure. Logically, this finding would be true for USGPIVs; however, this was not assessed in the current study.

A question still remains as to whether ultrasound guidance is itself responsible for the short survival of these lines or whether this is due to some other factor (eg, relatively short catheter length, the instability of thick subcutaneous adipose tissue, or greater friability of deeper veins). Because IV access using landmark techniques (often in the basilic region) has been performed for decades, it seems likely that deeper veins accessed by any method

would have an equally poor prognosis. To determine whether this is actually so will require further study.


Ultrasound provides a useful rescue method for establish- ing IV access in patients with DIVA. The current study reveals 2 factors that significantly affect the durability of these IVs–depth and location. Using a 48-mm catheter, vessels of 1.2 cm or more deep have a high likelihood of USGPIV failure and should only be cannulated when other options are not available. Vessels of less than 0.4 cm deep yield the best USGPIV longevity. Forearm and antecubital sites are more enduring than those in the upper arm. Understanding of these associations will help the sonologist select the optimal vessel for successful USGPIV cannulation and longevity.


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