Ultrasound-guided versus anatomical landmark-guided femoral venous access in cardiac electrophysiology procedures

Background Vascular access-site complications are a frequent cause of morbidity in cardiac electrophysiology (EP) procedures. Anatomical landmark-guided venous access is commonly used but is limited by anatomical variability and the inability to directly visualize vessels. Ultrasound-guided access provides real-time imaging, which may improve puncture accuracy and reduce complications. This systematic review and meta-analysis compares the safety and efficacy of ultrasound-guided versus anatomical landmark-guided venous access in adult EP patients. Methods A systematic search of PubMed, Embase, Scopus, Cochrane Library, and ClinicalTrials.gov was conducted up to March 2026. Both randomized and comparative observational studies in adult EP patients were included. The primary outcomes were total and major vascular complications. Secondary outcomes included minor vascular complications, inadvertent arterial puncture, total hematoma, total arteriovenous fistula, and total pseudoaneurysm. Pooled risk ratios (RRs) and Peto odds ratios (ORs), with corresponding 95% confidence intervals (CIs), were calculated using random-effects models. Statistical heterogeneity was assessed using the I² statistic. Results Twelve studies involving 10,982 patients (5,029 US-guided; 5,953 Anatomical landmark-guided) were included. Ultrasound guidance was associated with a reduction in total vascular complications (RR 0.42; 95% CI 0.31–0.56; I² = 28.5%) and major vascular complications (RR 0.44; 95% CI 0.35–0.56; I² = 0%). Minor complications were also reduced (RR 0.46; 95% CI 0.25–0.87; I² = 51.5%). Reductions were also seen in inadvertent arterial puncture (Peto OR 0.12; 95% CI 0.03–0.51; I² = 80.1%), total hematoma (Peto OR 0.45; 95% CI 0.33–0.63; I² = 22.1%), total arteriovenous fistula (Peto OR 0.32; 95% CI 0.15–0.67; I² = 0%), and total pseudoaneurysm (Peto OR 0.44; 95% CI 0.24–0.79; I² = 0%). However, the reduction in minor vascular complications and inadvertent arterial puncture was not statistically significant after Hartung–Knapp adjustment. Prediction intervals crossed the null for minor complications and inadvertent arterial puncture. Furthermore, the associations for pseudoaneurysm and minor vascular complications were not robust to sensitivity analyses after excluding influential studies. Conclusion Ultrasound-guided femoral venous access may reduce total and major vascular complications compared with anatomical landmark-guided techniques in cardiac electrophysiology procedures. However, current evidence is of very low certainty and is mainly driven by observational studies with historical controls. Hence higher-quality randomized trials are needed to confirm these findings.