Related Experiment Video
Updated: Oct 26, 2026
Upper-extremity Approach for Secondary Access in Transfemoral Transcatheter Aortic Valve Implantation
Published on: August 8, 2025
Risk-benefit profile of upper versus lower extremity peripherally inserted central catheter placement in neonates: A
Ying Xin Li1, Qiong Chen1, Yao Hua Wu1
1Department of Neonatology Nursing, West China Second University Hospital, Sichuan University, Sichuan, China; Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Chengdu, Sichuan, China.
Background:
The optimal insertion site for peripherally inserted central catheters in neonates remains uncertain. International guidelines differ in their recommendations regarding upper- versus lower-extremity placement, and existing systematic reviews are limited by small samples, narrow outcome coverage, or outdated evidence.
Objective:
To compare the potential risk-benefit profile of upper- versus lower-extremity peripherally inserted central catheter placement in neonates.
Design:
Systematic review and meta-analysis.
Methods:
MEDLINE, Embase, CENTRAL, and CINAHL were searched from inception to January 6, 2026, for studies comparing upper- versus lower-extremity placement in neonates. Primary outcomes were venous thromboembolism, central line-associated bloodstream infection, and catheter tip malposition; secondary outcomes included phlebitis, catheter migration, catheter leakage, catheter occlusion, catheter breakage, total complications, dwell time, unplanned removal, pericardial or pleural effusion, sepsis, and all-cause mortality. Two reviewers independently extracted data and assessed risk of bias. Crude estimates were pooled, sparse and heterogeneous adjusted estimates were summarised narratively, and certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation approach.
Results:
Twenty-one observational studies from 10 countries, involving 15,289 catheters, were included. For primary outcomes, upper-extremity placement was associated with a lower risk of venous thromboembolism (RR = 0.51, 95% CI 0.30-0.89; P = 0.017; low certainty) but higher risks of central line-associated bloodstream infection (RR = 1.44, 95% CI 1.07-1.95; P = 0.018; very low certainty) and catheter tip malposition (RR = 2.63, 95% CI 1.61-4.30; P < 0.001; very low certainty). For secondary outcomes, upper-extremity placement was associated with lower phlebitis risk (RR = 0.64, 95% CI 0.43-0.94; P = 0.022; low certainty) but higher risks of catheter migration (RR = 1.74, 95% CI 1.27-2.38; P < 0.001; low certainty), catheter leakage (RR = 2.24, 95% CI 1.35-3.73; P = 0.002; moderate certainty), and a marginally higher risk of unplanned removal (RR = 1.23, 95% CI 1.00-1.51; P = 0.048; very low certainty). A post hoc exploratory analysis suggested a possible higher risk of pericardial or pleural effusion (RR = 3.79, 95% CI 1.20-12.02; P = 0.024; very low certainty). No statistically significant between-site differences were observed for other secondary outcomes.
Conclusions:
Crude observational evidence suggested a potential bidirectional risk-benefit profile across catheter-related outcomes. The findings should be interpreted cautiously because non-randomised designs remain susceptible to residual confounding. The observed associations may inform risk-informed, individualised site selection but do not establish a universally preferred site. Prospective studies with standardised outcomes and adjusted analyses are needed.
Registration:
PROSPERO: CRD420251275788.
