Post-insertion outcomes of ultrasound-guided versus landmark peripheral intravenous catheters: a systematic review and meta-analysis

BACKGROUND: Ultrasound-guided (USG) peripheral intravenous catheter (PIVC) insertion improves cannulation success, particularly in patients with difficult intravenous access. Whether USG also improves post-insertion outcomes, including catheter failure, dwell time, and complications, remains uncertain. METHODS: We conducted a systematic review and meta-analysis of randomized controlled trials and comparative cohort studies comparing USG with landmark-guided PIVC insertion and reporting at least one post-insertion outcome. PubMed, Embase, Cochrane CENTRAL, and CINAHL were searched from January 2000 to March 2026. Risk of bias was assessed using RoB 2 and the Newcastle-Ottawa Scale. Random-effects meta-analysis used the DerSimonian-Laird estimator; REML with Hartung-Knapp-Sidik-Jonkman adjustment was performed as a post-hoc sensitivity analysis because few studies contributed to pooled outcomes. RESULTS: Fourteen studies (5 randomized trials, 9 cohort studies; 78,209 participants) were included. Catheter failure did not differ significantly between USG and landmark groups (k = 4; RR 1.23, 95% CI 0.99-1.51; p = 0.056), although the estimate was sensitive to model choice and exclusion of the largest study. Dwell time and extravasation were not pooled because of substantial heterogeneity (I² = 91.9% and 95.7%, respectively). Infiltration also showed no significant difference (k = 2; RR 0.68, 95% CI 0.12-3.83). Several studies reporting favorable USG outcomes were substantially confounded by systematic differences in catheter length or material between groups. CONCLUSIONS: Current evidence does not demonstrate a consistent post-insertion advantage of USG over landmark PIVC placement. Reported benefits in some studies may reflect catheter-specification differences rather than ultrasound guidance itself. Larger, well-controlled trials are needed.