Interventional News: Secure Strategies  
By Jon Bell, MSN, RN, VA-BC
Radiology Today
Vol. 24 No. 5 P. 28

Investigating Safe and Effective CVAD Securement 

Central vascular access devices (CVADs) are an essential part of patient care, acting as a lifeline for patients who require treatments like long-term medication, hydration, and nutrition delivery. Every year, radiologists and other clinicians insert thousands of central venous catheters (CVCs) and peripherally inserted central catheters (PICCs).

While there is ample research and standardized best practices regarding CVAD placement, very little research has been done to investigate best practices for securing these devices once they’re in place. The lack of focus on CVAD securement is particularly surprising, given that, in temporal terms, device placement takes minutes, but the access will need to last for days, months, or even years.

Proper securement is a critical component in the care and maintenance of any vascular access device.1 Unfortunately, it is often tradition and convenience— rather than evidence-based research— that determines the type of securement a clinician will use to keep CVADs in place. There is a pressing need for targeted research, particularly high-level randomized clinical trials, to evaluate the relative safety and efficacy of different securement methods, their impact on CVAD complications, and, ultimately, patient outcomes.

Confusing Standard of Care
Catheter migration and dislodgement have a tremendous impact on patient outcomes, as well as health care costs. The ideal securement method should prevent migration and dislodgment while also ensuring safety for the clinician and comfort for the patient. Currently, there are three main methods of securement2:

transdermal secures the catheter through the skin using sutures (also known as suture-based securement, or SBS);
cutaneous secures the catheter to the skin, including adhesive securement devices (ASDs), tissue adhesive, and integrated securement dressings; and
subcutaneous secures the catheter under the skin, also known as subcutaneous anchor securement systems (SASSs).

Unfortunately, the lack of high level studies comparing these different securement methods has created a fractured and confusing standard of care, with guidance that is often unclear and contradictory. Quite often, CVADs are secured differently depending on which device is used and who places them. Most CVCs are secured using suture-based systems, while the majority of PICCs are secured with a combination of dressings and ASDs. Physicians placing CVCs tend to suture, while nurses placing PICCs tend to use sutureless securement.

Perhaps the most startling example of this confusion is the continued ubiquity of suture-based CVAD securement. Sutures have never been classified as an external device securement tool by the FDA—meaning their use for CVAD securement is off-label—and numerous guidelines and standards explicitly discourage the use of SBS due to the risk of needlestick injuries. Yet SBS is still often the recommended securement method in physician and resident CVAD training and is readily available in insertion kits.

It is baffling that sutures continue to be used for catheter securement when so many other viable options exist. The safety and efficacy of engineered stabilization devices, including ASDs and SASS, have been well established, and there is substantial evidence that these devices are noninferior to suture-based systems.

Bringing Clarity to Confusion
This considerable inconsistency and confusion at the bedside regarding CVAD securement inspired our systematic review of more than 8,000 studies to determine the safety and efficacy of each method of securement that was published in the Journal of the Association for Vascular Access in 2022.

Upon reviewing the literature, we found that the safety and efficacy of CVAD securement have not, in fact, been systematically studied. Of 8,000 articles identified, only 39 of these had sufficient data to meet the inclusion criteria. Overall, the guidelines regarding securement noted that ASDs should be used rather than SBS to avoid injury. The evidence that engineered stabilization is noninferior to SBS is substantial; however, evidence comparing different forms of securement is lacking.

In the studies with good comparative data on rates of catheter migration and dislodgement, we also found clear benefits associated with SASS. The median incidence of migration and dislodgement for SASS was just 1.76%, compared with 4.17% for integrated devices, 6.77% for suture-based systems, and 9.69% for ASDs. While further research is needed, it increasingly appears that SASS is more effective at keeping CVADs in place compared with either adhesives or sutures.1

A Growing Body of Evidence
Our study adds to a growing body of evidence showing clear benefits with SASS compared with other securement methods. A recent 9,000-patient study examined a decade of data for both ASD and SASS and compared outcomes for migration or dislodgement and reaching the end of catheter necessity. For ASD-secured PICCs, migration and dislodgement caused premature removal of 12% of catheters, compared with just 0.4% of SASS-secured PICCs. The probability of reaching the end of need with one PICC for patients using an ASD was 68% at two years; the probability for patients with the SASS was over 95% at two years.1

With over 9,200 patients and more than a decade of assessment—representing more than a million catheter days—the study clearly demonstrated the SASS’s superiority in reducing the incidence of migration and dislodgement.

In addition, a 2020 study published in the American Journal of Infection Control showed a 288% increase in the relative risk of developing a central line–associated bloodstream infection in the group using adhesive securement methods compared with the group using SASS for catheter securement.3

The Future of CVAD Securement
It seems obvious that after placement, a CVAD should be secured in a way that keeps it firmly in place through daily use and during dressing changes. However, there appears to be an assumption that when it comes to catheter securement, the status quo is sufficient—despite the fact that there is little to no evidence supporting the status quo, as our systematic review revealed.

Moving forward, we need large-scale, randomized controlled trials to compare the safety and efficacy of the various securement methods and examine the actual effects of securement on patient outcomes. Additional studies are also needed to establish the correlation between securement and central line–associated bloodstream infection, as well as determine which securement method may be most effective at reducing these infections.

The current data on SASS show tremendous promise. While further study is needed, evidence increasingly suggests that SASS is superior to other securement methods—and may, in fact, be the future of CVAD securement. 

— Jon Bell, MSN, RN, VA-BC, has more than 25 years of emergency medical and 15 years of surgical care experience. He is a board certified vascular access specialist and clinical consultant.