**Background:** Central venous catheterization (CVC) is indicated in nearly 75% of intensive care patients for administration of venotoxic drugs, vasopressors, parenteral nutrition, and hemodynamic monitoring. Immediate complications occur in 8–15% of cases (pneumothorax, arterial puncture, bleeding, arrhythmias, catheter malposition) and are associated with patient factors (BMI <20 kg/m²) and operator factors (male gender, limited experience, ≥2 skin punctures). Late complications occur in approximately 2% of cases, mainly catheter-related infections (CRI) and thrombosis, which increase hospital length of stay, costs, and mortality. Despite strong evidence that real-time ultrasound (US)-guidance reduces immediate complications threefold for internal jugular vein (IJV) and femoral vein (FV) sites and twofold for subclavian vein (SV)/proximal axillary vein (AV) sites, US-guidance remains underused (36–68% of insertions, <30% for subclavian site), with common barriers including perceived lack of usefulness (36%), unavailability of US machines (33%), and perceived prolonged procedure time (19%).
**Methods:** This narrative review screened PubMed for in-ICU or operating room studies on US-guided CVC with short-term catheters in adult patients published since 2020, with earlier studies extracted from international guidelines. The review summarizes 2020 international guideline recommendations and highlights innovations published since that date, focusing on optimal puncture techniques, new technologies, and development of alternative access sites.
**Key Results:** Regarding puncture technique, one RCT on proximal AV/SV catheterization found significant superiority of out-of-plane short-axis (OOP-SA) versus in-plane long-axis (IP-LA) puncture, with shorter insertion time (69 vs 98 s, p=0.040), higher overall success rate (96% vs 78%, p<0.001), first-puncture success rate (86% vs 67%, p=0.003), first-puncture single-pass success rate (72% vs 48%, p=0.002), fewer needle redirections (0.39±0.88 vs 0.88±1.15, p=0.001), fewer skin punctures (1.12±0.38 vs 1.28±0.54, p=0.019), and fewer complications (3% vs 13%, p=0.028, with arterial puncture 7% vs 0%, p=0.014). However, meta-analyses of RCTs for IJV catheterization found no superiority of one puncture technique over another. For new technologies, a simulation study of a magnetic needle-pilot system for AV/SV catheterization showed significantly shorter time to successful cannulation, fewer skin punctures, fewer posterior wall punctures, fewer needle redirections, and better operator comfort regardless of experience. An RCT of a needle depth guard on 419 patients found significantly higher first-attempt IJV cannulation success with the guard (98.6% vs 85.7%, p=0.007), with fewer posterior wall punctures (0.5% vs 8.61%, p=0.001) and common carotid punctures (0% vs 7.18%, p=0.001). For alternative access sites, a single-center observational study found lower CRBSI incidence with low IJV versus high IJV access (1.2 vs 4.8 per 1000 catheter-days, OR=3.9; 95% CI 1.1–infinite; p=0.03). A pilot RCT comparing low IJV and proximal AV/SV catheterization (n=201) found overall success rates of 96% and 89%, first-puncture success rates of 90% and 80%, and overall immediate complication rates of 11.6% and 14.6%, respectively. For supraclavicular subclavian vein (SSV) catheterization versus OOP-SA IJV, one RCT reported significantly higher first-attempt success (83.2% vs 63.2%, p=0.001), shorter insertion time (43.98±26.77 vs 53.12±40.21 s, p=0.038), fewer puncture attempts (1.16±0.39 vs 1.47±0.71, p<0.001), fewer needle redirections (0.69±0.58 vs 1.17±0.95, p<0.001), less difficulty in guidewire advancement (2.4% vs 27.4%, p<0.001), and less venous collapse (2.4% vs 18.4%, p<0.001). For distal AV versus proximal AV/SV, one RCT found more arterial punctures with distal AV (6.5% vs 0%) but less pneumothorax (0% vs 3.3%), while another RCT in cardiac surgery found proximal group had higher first-puncture success (75.8% vs 51.5%, p<0.001), fewer attempts (1.3±0.7 vs 1.7±0.9, p<0.01), and less access time (20 [15;28] vs 30 [19;42] s, p<0.001).
**Clinical Implications:** The review reinforces that real-time US-guidance should be first-line for all CVC sites per 2020 guidelines, and that the infraclavicular proximal AV/SV site remains the recommended first choice to reduce late infectious and thrombotic complications. However, US-guidance remains underused, and efforts should focus on improving compliance through training, simulation, and adoption of new technologies. Emerging techniques such as in-plane oblique-axis puncture, supraclavicular subclavian/brachiocephalic vein approaches, and distal IJV access show promise for improving safety and feasibility, particularly for the subclavian site. New technologies including magnetic needle-pilot systems, photoacoustic needles, needle depth guards, and smart glasses may further improve operator comfort and procedural success, though most require validation in clinical ICU settings. Importantly, high-level evidence comparing infectious complications across these new approaches is lacking, and large RCTs are needed before firm recommendations can be made. Clinicians should be familiar with multiple techniques to personalize CVC insertion based on patient anatomy, risk factors, and clinical context.