The American Society of Echocardiography has released updated guidelines for ultrasound-guided vascular cannulation, reinforcing recommendations for ultrasound guidance in various vascular access procedures while recognizing remaining evidence gaps.

Published in the Journal of the American Society of Echocardiography, these guidelines replace the American Society of Echocardiography's (ASE) 2011 recommendations, incorporating expert consensus on best practices and techniques.

"There is an increasing body of literature indicating that [ultrasound] (US)-guided vascular access improves success rates and reduces complications, although the quality of the evidence to date remains weak," the guideline authors wrote. "The availability of US equipment and clinical proficiency will more likely influence the role of US-guided vascular access as a standard of care than will future research studies," they noted.

The guidelines provide Grade 1A (strong recommendation, high-quality evidence) support for US guidance during internal jugular vein cannulation. Other recommendations include:

• Subclavian vein: Grade 1C (strong recommendation, low-quality evidence)
• Axillary vein: Grade 1B (strong recommendation, moderate-quality evidence)
• Femoral vein: Grade 1B (strong recommendation, moderate-quality evidence)
• Radial artery: Grade 1B for routine use, Grade 1A for patients with weak pulses, small arteries, or failed landmark attempts
• Peripheral intravenous central catheter (PICC) placement: Grade 1C
• Peripheral intravenous cannulation in adults with moderate to difficult venous access: Grade 1B
• Pediatric internal jugular vein cannulation: Grade 1A.

The guidelines outline three key applications of US during vascular access:

• Precannulation vessel assessment
• Dynamic US guidance during cannulation
• Identification of local complications.

For complications surveillance, the guidelines emphasize that "two-dimensional and color Doppler US imaging may identify early and late complications," including hematoma, thrombosis, arteriovenous fistula formation, and pseudoaneurysm development.

ASE recommends structured training for practitioners, including didactic education and hands-on simulation prior to patient procedures. While previous guidelines suggested a minimum of 10 supervised procedures for competence, the updated recommendations note that some experts now advise at least 30 successful procedures within 12 months.

"The expanding use of US in clinical practice has been associated with the need for increasing educational efforts," the guideline authors indicated. "[T]raining in US-guided vascular cannulation includes three components: knowledge acquisition, simulation training, and supervised practice," they emphasized.

Despite the strong recommendations, the guideline authors acknowledge ongoing evidence gaps, particularly regarding optimal training methods and the comparative effectiveness of different US techniques. However, they argue that the practical benefits of US guidance justify strong recommendations across most vascular access scenarios.

The guidelines were developed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to assess evidence levels and recommendation grades.

Full disclosures can be found in the guidelines.