Puncture site versus exit site in central venous access procedures: Still a source of confusion

Two major innovations-ultrasound guidance and catheter tunneling-have transformed central venous catheterization, significantly reducing early and late complications. Ultrasound enables accurate vein selection based on anatomical and functional criteria, facilitates safer venipuncture, and broadens access to previously avoided veins (e.g. brachiocephalic, axillary). It also allows real-time guidance for wire direction, tip navigation, and the immediate diagnosis of complications. Tunneling, once exclusive to cuffed catheters, is now increasingly used for non-cuffed devices to optimize the exit site independently of the venipuncture site. This strategy reduces infection, thrombosis, and dislodgment risks by relocating exit from high-risk zones (e.g. groin, neck) to cleaner, more secure areas. Despite widespread adoption of these innovations, current guidelines often confuse puncture and exit sites, leading to outdated recommendations. For example, guidelines labeling femoral or jugular access as high-risk often fail to differentiate between venipuncture and exit locations. Ultrasound-guided femoral puncture with tunneling can yield low-thrombosis, low-infection configurations, especially with mid-thigh or abdominal exit sites. Similarly, supraclavicular puncture of the internal jugular vein with tunneling avoids the traditional high-neck exit and its associated complications. Recommendations promoting subclavian access are also problematic, as safe ultrasound access is often only feasible via supraclavicular routes, not by traditional blind infraclavicular approaches. The field must shift from old anatomical dogma to ultrasound-based, tunneled approaches tailored to each patients need. Clear distinction between venipuncture and exit sites is essential for modern, evidence-based vascular access practices.