Download PDF
Open Access
CC BY 4.0 · TH Open 2025; 09: a27700060
DOI: 10.1055/a-2770-0060
Review Article

Bleeding Risk of Central Venous Catheterization in Adults: A Systematic Review and Meta-analysis

Authors

  • Nicola Mumoli 

    1   Department of Cardiovascular Medicine, ASST Valle Olona, Ospedale di Circolo, Busto Arsizio (VA), Italy

  • Lucia Colavolpe

    1   Department of Cardiovascular Medicine, ASST Valle Olona, Ospedale di Circolo, Busto Arsizio (VA), Italy

  • Piero Tarantini

    1   Department of Cardiovascular Medicine, ASST Valle Olona, Ospedale di Circolo, Busto Arsizio (VA), Italy

  • Aldo Fici

    1   Department of Cardiovascular Medicine, ASST Valle Olona, Ospedale di Circolo, Busto Arsizio (VA), Italy

  • Stefania Marengo

    2   Department of Internal Medicine, Azienda Ospedaliera, Ordine Mauriziano, Turin, Italy

  • Riccardo Capra

    1   Department of Cardiovascular Medicine, ASST Valle Olona, Ospedale di Circolo, Busto Arsizio (VA), Italy

  • Francesco Cei

    3   1st Internal Medicine, Department of Medicine, Azienda USL Toscana Centro, Sede di Empoli, Italy
Further Information
Also available at
  Permissions and Reprints


Graphical Abstract

Abstract

Background

Central venous catheter (CVC) insertion is a cornerstone procedure in hospitalized and critically ill adults. However, many patients requiring CVCs have coagulopathy, thrombocytopenia, liver disease, or hematologic malignancies, raising concerns about bleeding risk. The true incidence of hemorrhagic complications and the value of preventive measures in these populations remain uncertain.

Objective

The objective of this study is to systematically evaluate the incidence of bleeding related to CVC placement in adults at increased hemorrhagic risk and to assess the effectiveness of periprocedural preventive strategies.

Methods

PubMed, Embase, Cochrane Library, and Web of Science were searched from January 2000 to March 2025. Randomized trials and observational studies involving adults with elevated bleeding risk undergoing CVC placement were included. Data extraction and risk of bias assessment (RoB 2 and Newcastle–Ottawa Scale) were performed independently by two reviewers. Certainty of evidence was rated using GRADE (Grading of Recommendations Assessment, Development, and Evaluation), and random-effects meta-analyses were conducted when appropriate.

Results

Forty-one studies encompassing 7,603 patients and 8,796 CVC insertions were analyzed. Major bleeding occurred in 0.57% of procedures and minor bleeding in 8.1%. The pooled incidence of any bleeding across 22 studies was 6.8% (95% confidence interval, 3.7–10.7%). Bleeding was more frequent among patients with hematologic malignancies, severe thrombocytopenia, or critical illness. Ultrasound guidance markedly reduced complications compared with landmark technique. Platelet transfusion was effective only below 30 × 109/L, whereas fresh-frozen plasma showed no clear benefit.

Conclusions

CVC placement in adults with coagulopathy or thrombocytopenia is generally safe. Ultrasound guidance, restrictive transfusion thresholds, and thromboelastography-guided assessment enhance procedural safety and reduce unnecessary transfusions.

Keywords

CVC - bleeding risk - ultrasound-guided procedures - critically ill patients - blood products transfusions

Note

[Figs. 2], [3], and [4] were generated with MedCalc. (https://www.medcalc.org/en/).




Publication History

Received: 28 November 2025

Accepted: 10 December 2025

Accepted Manuscript online:
11 December 2025

Article published online:
29 December 2025

© 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

Georg Thieme Verlag KG
Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany

Bibliographical Record
Nicola Mumoli, Lucia Colavolpe, Piero Tarantini, Aldo Fici, Stefania Marengo, Riccardo Capra, Francesco Cei. Bleeding Risk of Central Venous Catheterization in Adults: A Systematic Review and Meta-analysis. TH Open 2025; 09: a27700060.
DOI: 10.1055/a-2770-0060
 

  • References

  • 1 Kornbau C, Lee KC, Hughes GD, Firstenberg MS. Central line complications. Int J Crit Illn Inj Sci 2015; 5 (03) 170-178
    Search in Google Scholar
  • 2 Parienti JJ, Mongardon N, Mégarbane B. et al; 3SITES Study Group. Intravascular complications of central venous catheterization by insertion site. N Engl J Med 2015; 373 (13) 1220-1229
    Search in Google Scholar
  • 3 Padmanabhan A, Connelly-Smith L, Aqui N. et al. Guidelines on the use of therapeutic apheresis in clinical practice - evidence-based approach from the Writing Committee of the American Society for Apheresis: the Eighth Special Issue. J Clin Apher 2019; 34 (03) 171-354
    Search in Google Scholar
  • 4 McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med 2003; 348 (12) 1123-1133
    Search in Google Scholar
  • 5 Mermel LA, Allon M, Bouza E. et al. Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 Update by the Infectious Diseases Society of America. Clin Infect Dis 2009; 49 (01) 1-45
    Search in Google Scholar
  • 6 Cosmi B, Alatri A, Cattaneo M. et al; Italian Society for Haemostasis and Thrombosis. Assessment of the risk of bleeding in patients undergoing surgery or invasive procedures: guidelines of the Italian Society for Haemostasis and Thrombosis (SISET). Thromb Res 2009; 124 (05) e6-e12
    Search in Google Scholar
  • 7 Frykholm P, Pikwer A, Hammarskjöld F. et al; Swedish Society of Anaesthesiology and Intensive Care Medicine. Clinical guidelines on central venous catheterisation. Acta Anaesthesiol Scand 2014; 58 (05) 508-524
    Search in Google Scholar
  • 8 Dumaine CS, Brown RS, MacRae JM, Oliver MJ, Ravani P, Quinn RR. Central venous catheters for chronic hemodialysis: is “last choice” never the “right choice”?. Semin Dial 2018; 31 (01) 3-10
    Search in Google Scholar
  • 9 Page MJ, McKenzie JE, Bossuyt PM. et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021; 372: n71
    Search in Google Scholar
  • 10 Sterne JAC, Savović J, Page MJ. et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ 2019; 366: l4898
    Search in Google Scholar
  • 11 Stang A. Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. Eur J Epidemiol 2010; 25 (09) 603-605
    Search in Google Scholar
  • 12 Guyatt GH, Oxman AD, Vist GE. et al; GRADE Working Group. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ 2008; 336 (7650) 924-926
    Search in Google Scholar
  • 13 Schulman S, Kearon C. Subcommittee on Control of Anticoagulation of the Scientific and Standardization Committee of the International Society on Thrombosis and Haemostasis. Definition of major bleeding in clinical investigations of antihemostatic medicinal products in non-surgical patients. J Thromb Haemost 2005; 3 (04) 692-694
    Search in Google Scholar
  • 14 National Cancer Institute. Common Terminology Criteria for Adverse Events (CTCAE) v 6.0. NIH, U.S. Department of Health and Human Services; 2020. . Accessed at: https://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm
    Search in Google Scholar
  • 15 Müller MC, Arbous MS, Spoelstra-de Man AM. et al. Transfusion of fresh-frozen plasma in critically ill patients with a coagulopathy before invasive procedures: a randomized clinical trial (CME). Transfusion 2015; 55 (01) 26-35 , quiz 25
    Search in Google Scholar
  • 16 van Baarle FLF, Tisheh A, Jhingoeriesingh SS, Vlaar APJ, Biemond BJ. Contribution of coagulopathy on the risk of bleeding after central venous catheter placement in critically Ill thrombocytopenic patients. Crit Care Explor 2022; 4 (01) e0621
    Search in Google Scholar
  • 17 Karakitsos D, Labropoulos N, De Groot E. et al. Real-time ultrasound-guided catheterisation of the internal jugular vein: a prospective comparison with the landmark technique in critical care patients. Crit Care 2006; 10 (06) R162
    Search in Google Scholar
  • 18 Rockholt MM, Thorarinsdottir HR, Lazarevic V, Rundgren M, Kander T. Central venous catheter-related complications in hematologic patients: an observational study. Acta Anaesthesiol Scand 2022; 66 (04) 473-482
    Search in Google Scholar
  • 19 Potet J, Arnaud FX, Thome A. et al. Peripherally inserted central catheter placement in patients with coagulation disorders: a retrospective analysis. Diagn Interv Imaging 2015; 96 (11) 1147-1151
    Search in Google Scholar
  • 20 Vinson DR, Ballard DW, Hance LG. et al; Kaiser Permanente CREST Network Investigators. Bleeding complications of central venous catheterization in septic patients with abnormal hemostasis. Am J Emerg Med 2014; 32 (07) 737-742
    Search in Google Scholar
  • 21 Wodajo A, Sarode R, Valiyaparambil S. et al. A lower fibrinogen threshold does not lead to increased bleeding risk in patients receiving therapeutic plasma exchange: a prospective single-center analysis. Transfusion 2024; 64 (06) 1076-1082
    Search in Google Scholar
  • 22 Shah A, Amarapurkar D, Dharod M. et al. Coagulopathy in cirrhosis: a prospective study to correlate conventional tests of coagulation and bleeding following invasive procedures in cirrhotics. Indian J Gastroenterol 2015; 34 (05) 359-364
    Search in Google Scholar
  • 23 Haas B, Chittams JL, Trerotola SO. Large-bore tunneled central venous catheter insertion in patients with coagulopathy. J Vasc Interv Radiol 2010; 21 (02) 212-217
    Search in Google Scholar
  • 24 Zeidler K, Arn K, Senn O, Schanz U, Stussi G. Optimal preprocedural platelet transfusion threshold for central venous catheter insertions in patients with thrombocytopenia. Transfusion 2011; 51 (11) 2269-2276
    Search in Google Scholar
  • 25 Sohail MA, Vachharajani TJ, Lane JE. et al. Thromboelastography-guided correction of coagulopathy before tunneled central venous access in critically ill patients with liver disease: a propensity score-matched study. Crit Care Explor 2023; 5 (12) e1023
    Search in Google Scholar
  • 26 Boban A, Lambert C, Hermans C. The use of short-term central venous catheters for optimizing continuous infusion of coagulation factor concentrate in haemophilia patients undergoing major surgical procedures. Haemophilia 2015; 21 (05) e364-e368
    Search in Google Scholar
  • 27 Björkander M, Bentzer P, Schött U, Broman ME, Kander T. Mechanical complications of central venous catheter insertions: a retrospective multicenter study of incidence and risks. Acta Anaesthesiol Scand 2019; 63 (01) 61-68
    Search in Google Scholar
  • 28 Weigand K, Encke J, Meyer FJ. et al. Low levels of prothrombin time (INR) and platelets do not increase the risk of significant bleeding when placing central venous catheters. Med Klin (Munich) 2009; 104 (05) 331-335
    Search in Google Scholar
  • 29 Rees PS, Lamb LE, Nicholson-Roberts TC. et al. Safety and feasibility of a strategy of early central venous catheter insertion in a deployed UK military Ebola virus disease treatment unit. Intensive Care Med 2015; 41 (05) 735-743
    Search in Google Scholar
  • 30 Della Vigna P, Monfardini L, Bonomo G. et al. Coagulation disorders in patients with cancer: nontunneled central venous catheter placement with US guidance–a single-institution retrospective analysis. Radiology 2009; 253 (01) 249-252
    Search in Google Scholar
  • 31 Cao M, Hong J, Zhang D, Chen F, Su Y. Central venous catheters do not increase the hemorrhagic risk in acute promyelocytic leukemia patients during induction therapy. Front Oncol 2024; 14: 1332372
    Search in Google Scholar
  • 32 Kwon JO, MacLaren R. Comparison of fresh-frozen plasma, four-factor prothrombin complex concentrates, and recombinant factor VIIa to facilitate procedures in critically ill patients with coagulopathy from liver disease: a retrospective cohort study. Pharmacotherapy 2016; 36 (10) 1047-1054
    Search in Google Scholar
  • 33 Farina A, Coppola G, Bassanelli G. et al. Ultrasound-guided central venous catheter placement through the axillary vein in cardiac critical care patients: safety and feasibility of a novel technique in a prospective observational study. Minerva Anestesiol 2020; 86 (02) 157-164
    Search in Google Scholar
  • 34 Lukas P, Durila M, Jonas J, Vymazal T. Evaluation of thromboelastometry in sepsis in correlation with bleeding during invasive procedures. Clin Appl Thromb Hemost 2018; 24 (06) 993-997
    Search in Google Scholar
  • 35 Glen H, Lang I, Christie L. Infraclavicular axillary vein cannulation using ultrasound in a mechanically ventilated general intensive care population. Anaesth Intensive Care 2015; 43 (05) 635-640
    Search in Google Scholar
  • 36 Napolitano M, Malato A, Raffaele F. et al. Ultrasonography-guided central venous catheterisation in haematological patients with severe thrombocytopenia. Blood Transfus 2013; 11 (04) 506-509
    Search in Google Scholar
  • 37 Cavanna L, Citterio C, Nunzio Camilla D, Orlandi E, Toscani I, Ambroggi M. Central venous catheterization in cancer patients with severe thrombocytopenia: ultrasound-guide improves safety avoiding prophylactic platelet transfusion. Mol Clin Oncol 2020; 12 (05) 435-439
    Search in Google Scholar
  • 38 Cortelezzia A, Fracchiolla NS, Maisonneuve P. et al. Central venous catheter-related complications in patients with hematological malignancies: a retrospective analysis of risk factors and prophylactic measures. Leuk Lymphoma 2003; 44 (09) 1495-1501
    Search in Google Scholar
  • 39 Nosari AM, Nador G, De Gasperi A. et al. Prospective monocentric study of non-tunnelled central venous catheter-related complications in hematological patients. Leuk Lymphoma 2008; 49 (11) 2148-2155
    Search in Google Scholar
  • 40 Potet J, Thome A, Curis E. et al. Peripherally inserted central catheter placement in cancer patients with profound thrombocytopaenia: a prospective analysis. Eur Radiol 2013; 23 (07) 2042-2048
    Search in Google Scholar
  • 41 Kander T, Tanaka KA, Norström E, Persson J, Schött U. The effect and duration of prophylactic platelet transfusions before insertion of a central venous catheter in patients with bone marrow failure evaluated with point-of-care methods and flow cytometry. Anesth Analg 2014; 119 (04) 882-890
    Search in Google Scholar
  • 42 AlRstum ZA, Huynh TT, Huang SY, Pisimisis GT. Risk of bleeding after ultrasound-guided jugular central venous catheter insertion in severely thrombocytopenic oncologic patients. Am J Surg 2019; 217 (01) 133-137
    Search in Google Scholar
  • 43 Jing W, Rong H, Li J, Xia ZH, Yu ZH, Ke Z. The power peripherally inserted central catheter is superior to a central venous catheter in management of patients with esophageal variceal bleeding undergoing devascularization. J Pak Med Assoc 2016; 66 (10) S59-S61
    Search in Google Scholar
  • 44 Pandey CK, Saluja V, Gaurav K, Tandon M, Pandey VK, Bhadoria AS. K time & maximum amplitude of thromboelastogram predict post-central venous cannulation bleeding in patients with cirrhosis: a pilot study. Indian J Med Res 2017; 145 (01) 84-89
    Search in Google Scholar
  • 45 van Baarle FLF, van de Weerdt EK, van der Velden WJFM. et al. Platelet transfusion before CVC placement in patients with thrombocytopenia. N Engl J Med 2023; 388 (21) 1956-1965
    Search in Google Scholar
  • 46 Carino GP, Tsapenko AV, Sweeney JD. Central line placement in patients with and without prophylactic plasma. J Crit Care 2012; 27 (05) 529.e9-529.e13
    Search in Google Scholar
  • 47 Theodoro D, Krauss M, Kollef M, Evanoff B. Risk factors for acute adverse events during ultrasound-guided central venous cannulation in the emergency department. Acad Emerg Med 2010; 17 (10) 1055-1061
    Search in Google Scholar
  • 48 Nasr-Esfahani M, Kolahdouzan M, Mousavi SA. Inserting central venous catheter in emergency conditions in coagulopathic patients in comparison to noncoagulopathic patients. J Res Med Sci 2016; 21: 120
    Search in Google Scholar
  • 49 Zarama V, Revelo-Noguera J, Quintero JA. et al. Prophylactic platelet transfusion and risk of bleeding associated with ultrasound-guided central venous access in patients with severe thrombocytopenia. Acad Emerg Med 2023; 30 (06) 644-652
    Search in Google Scholar
  • 50 Haque W, Alvarenga M, Vuppala S, Reddy M, Sarode R. Retrospective analysis of bleeding events after central venous catheter placement in thrombotic thrombocytopenic purpura. Transfus Apher Sci 2021; 60 (03) 103120
    Search in Google Scholar
  • 51 Duffy SM, Coyle TE. Platelet transfusions and bleeding complications associated with plasma exchange catheter placement in patients with presumed thrombotic thrombocytopenic purpura. J Clin Apher 2013; 28 (05) 356-358
    Search in Google Scholar
  • 52 Langley AR, Stain AM, Chan A. et al. Experience with central venous access devices (CVADs) in the Canadian hemophilia primary prophylaxis study (CHPS). Haemophilia 2015; 21 (04) 469-476
    Search in Google Scholar
  • 53 Thompson CA, Kyle R, Gertz M, Heit J, Pruthi R, Pardanani A. Systemic AL amyloidosis with acquired factor X deficiency: a study of perioperative bleeding risk and treatment outcomes in 60 patients. Am J Hematol 2010; 85 (03) 171-173
    Search in Google Scholar
  • 54 Erkurt MA, Berber I, Berktas HB. et al. A life-saving therapy in Class I HELLP syndrome: therapeutic plasma exchange. Transfus Apher Sci 2015; 52 (02) 194-198
    Search in Google Scholar
  • 55 Yeh JH, Chiu HC. Coagulation abnormalities in serial double-filtration plasmapheresis. J Clin Apher 2001; 16 (03) 139-142
    Search in Google Scholar
  • 56 Anthon CT, Pène F, Perner A. et al; On behalf of the PLOT-ICU Collaborators and the Nine-I Study Group. Thrombocytopenia and platelet transfusions in ICU patients: an international inception cohort study (PLOT-ICU). Intensive Care Med 2023; 49 (11) 1327-1338
    Search in Google Scholar
  • 57 Fong C, Tan CWC, Tan DKY, See KC. Safety of thoracentesis and tube thoracostomy in patients with uncorrected coagulopathy: a systematic review and meta-analysis. Chest 2021; 160 (05) 1875-1889
    Search in Google Scholar
  • 58 van de Weerdt EK, Biemond BJ, Baake B. et al. Central venous catheter placement in coagulopathic patients: risk factors and incidence of bleeding complications. Transfusion 2017; 57 (10) 2512-2525
    Search in Google Scholar
  • 59 Crăciun R, Grapă C, Mocan T. et al. The bleeding edge: managing coagulation and bleeding risk in patients with cirrhosis undergoing interventional procedures. Diagnostics (Basel) 2024; 14 (22) 2602
    Search in Google Scholar
  • 60 Abia-Trujillo D, Funes-Ferrada R, Vaca-Cartagena BF. et al. Bleeding risk assessment with thromboelastography in interventional pulmonology procedures. Respir Med 2025; 238: 107964
    Search in Google Scholar
  • 61 Coz Yataco A, Soghier I, Hébert PC. et al. Transfusion of fresh frozen plasma and platelets in critically ill adults: an American College of Chest Physicians Clinical Practice guideline. Chest 2025; 168 (03) 661-676
    Search in Google Scholar
  • 62 Lester W, Bent C, Alikhan R. et al; BSH Committee. A British Society for Haematology guideline on the assessment and management of bleeding risk prior to invasive procedures. Br J Haematol 2024; 204 (05) 1697-1713
    Search in Google Scholar
  • 63 Boccatonda A, Baldini C, Rampoldi D. et al. Ultrasound-assisted and ultrasound-guided thoracentesis: an educational review. Diagnostics (Basel) 2024; 14 (11) 1124
    Search in Google Scholar
  • 64 Soni NJ, Franco-Sadud R, Schnobrich D. et al. Ultrasound guidance for lumbar puncture. Neurol Clin Pract 2016; 6 (04) 358-368
    Search in Google Scholar
  • 65 Brass P, Hellmich M, Kolodziej L, Schick G, Smith AF. Ultrasound guidance versus anatomical landmarks for subclavian or femoral vein catheterization. Cochrane Database Syst Rev 2015; 1 (01) CD011447
    Search in Google Scholar