Bleeding Risk of Central Venous Catheterization in Adults: A Systematic Review and Meta-analysis.

Background: Central venous catheter (CVC) insertion is a cornerstone procedure in hospitalized and critically ill adults. However, many patients requiring CVCs have coagulopathy, thrombocytopenia, liver disease, or hematologic malignancies, raising concerns about bleeding risk. The true incidence of hemorrhagic complications and the value of preventive measures in these populations remain uncertain. Objective: The objective of this study is to systematically evaluate the incidence of bleeding related to CVC placement in adults at increased hemorrhagic risk and to assess the effectiveness of periprocedural preventive strategies. Methods: PubMed, Embase, Cochrane Library, and Web of Science were searched from January 2000 to March 2025. Randomized trials and observational studies involving adults with elevated bleeding risk undergoing CVC placement were included. Data extraction and risk of bias assessment (RoB 2 and Newcastle-Ottawa Scale) were performed independently by two reviewers. Certainty of evidence was rated using GRADE (Grading of Recommendations Assessment, Development, and Evaluation), and random-effects meta-analyses were conducted when appropriate. Results: Forty-one studies encompassing 7,603 patients and 8,796 CVC insertions were analyzed. Major bleeding occurred in 0.57% of procedures and minor bleeding in 8.1%. The pooled incidence of any bleeding across 22 studies was 6.8% (95% confidence interval, 3.7-10.7%). Bleeding was more frequent among patients with hematologic malignancies, severe thrombocytopenia, or critical illness. Ultrasound guidance markedly reduced complications compared with landmark technique. Platelet transfusion was effective only below 30 × 10 9 /L, whereas fresh-frozen plasma showed no clear benefit. Conclusions: CVC placement in adults with coagulopathy or thrombocytopenia is generally safe. Ultrasound guidance, restrictive transfusion thresholds, and thromboelastography-guided assessment enhance procedural safety and reduce unnecessary transfusions.