We read with great interest the article by Hong et al., “Securement of Central Venous Catheters: Suture Fixation vs. Stabilization Devices in a Multicenter Retrospective Study [
1].” The authors should be commended for addressing an important but often overlooked component of central venous catheter (CVC) management. Their study demonstrates an intriguing clinical trade-off: adhesive-pad stabilization devices (SDs) were associated with a higher risk of catheter dislocation than suture fixation (SF), whereas several analyses suggested a potentially lower risk of central line–associated bloodstream infection (CLABSI) with SDs. Beyond the direct comparison of these two techniques, their findings raise a broader and perhaps more clinically relevant question: Should CVC securement be selected according to the individual mechanical and infectious risks of each patient?
CVC securement is sometimes regarded as a minor technical step after successful catheter insertion. However, securement must fulfill two potentially competing objectives: maintaining sufficient mechanical stability to prevent catheter migration or accidental removal while minimizing skin injury and potential routes for microbial colonization. Hong et al. [
1] demonstrate this tension particularly well. After propensity-score matching, dislocation occurred more frequently with SDs than with SF, and SD use remained independently associated with dislocation in multivariable analysis (adjusted HR, 2.23; 95% CI, 1.11 to 4.48) [
1]. Conversely, CLABSI occurred less frequently in the SD group in incidence-rate and Kaplan-Meier analyses, although the association did not remain statistically significant in the primary multivariable Cox model (adjusted HR, 0.49; 95% CI, 0.13 to 1.82) [
1].
These findings suggest that the clinically relevant question may not be whether one securement method is universally superior to another. Rather, the probability and clinical consequences of each complication should be considered for an individual patient. Catheter dislocation may often be managed by reinsertion, but the consequences of catheter loss vary substantially. Accidental removal may be particularly consequential in patients with limited venous access, those receiving continuous vasoactive or other critical infusions, or those in whom repeat catheterization is expected to be technically difficult or hazardous. In such circumstances, maximizing mechanical security may reasonably take priority.
Conversely, the balance may shift in patients expected to require prolonged catheterization or those at particularly high risk for infection. Sutures create additional breaches of the skin barrier adjacent to the catheter exit site and introduce foreign material that may facilitate microbial colonization. Current infusion therapy standards recommend consideration of alternatives to sutures as part of contemporary vascular access management [
2]. Although the present study cannot establish a causal protective effect of SDs against CLABSI, the observed signal deserves attention because bloodstream infection can have substantially greater clinical consequences than uncomplicated catheter replacement.
Importantly, however, “sutureless securement” should not be considered a single intervention. A recent systematic review and meta-analysis including 46 studies and 10,054 participants demonstrated substantial heterogeneity among catheter types, patient populations, dressings, and securement technologies and emphasized the limited certainty of evidence for several outcomes [
3]. A recent prospective cohort study comparing an integrated securement device with sutures for centrally inserted CVCs found no significant difference in complete or partial catheter dislodgement, while the integrated device improved patient comfort and prolonged maintenance intervals [
4]. These findings differ somewhat from those of Hong et al. [
1] and reinforce the concept that results obtained with one securement technology should not automatically be generalized to all sutureless devices.
Therefore, CVC securement might be better conceptualized as a risk-adapted strategy rather than a binary choice between sutures and SDs. The optimal strategy should consider not only the fixation device but also catheter type, number of lumens, access site, anticipated dwell time, patient mobility or agitation, skin condition, availability of alternative venous access, type of infusion, and the clinical consequences of catheter loss. Nursing factors—including dressing technique, frequency of dressing changes, catheter surveillance, and familiarity with a particular securement system—are also likely to influence outcomes.
The present study itself provides support for such a multidimensional approach. Triple-lumen catheter use was independently associated with CLABSI (adjusted HR, 2.93) [
1], consistent with previous evidence linking multilumen catheters with increased bloodstream infection risk [
5]. Thus, infection risk cannot be attributed to securement technique alone. Similarly, the mechanical risk of dislocation is likely influenced by patient movement, catheter location, external catheter length, dressing integrity, and local catheter-care practices.
From a practical standpoint, securement could therefore be considered along two principal dimensions: the risk and consequence of catheter dislocation and the risk and consequence of catheter-related infection. A patient with difficult venous access receiving an indispensable continuous infusion may warrant a strategy prioritizing mechanical stability. In contrast, a patient requiring prolonged catheterization who has a high infectious risk and readily available alternative venous access may favor a strategy minimizing skin penetration. Between these extremes, combinations of contemporary technologies—including adhesive-pad devices, integrated securement dressings, tissue adhesives, or subcutaneous anchor systems—may eventually allow securement to be tailored more precisely to individual clinical circumstances.
This interpretation also highlights an important limitation of the study by Hong et al. [
1]. SDs were used at one institution, whereas SF was used at the other two institutions [
1]. Consequently, securement technique was closely linked to institutional practice. The substantial differences in ICU admission, clinical indication, access site, and catheter dwell time between the original groups suggest important differences in patient populations and catheter-management patterns. Although propensity-score matching and multiple sensitivity analyses strengthen the study, unmeasured differences in nursing care, dressing protocols, patient mobilization, catheter surveillance, and thresholds for catheter replacement cannot be completely separated from the effect of securement technique.
Of particular methodological interest, the analyses described as evaluating institution-level clustering used matched subclass as the random effect or clustering variable rather than institution itself [
1]. These analyses appropriately address dependence related to propensity-score matching but do not directly disentangle the effect of institution from that of securement method. Indeed, because securement method was essentially determined by institution, the two effects are intrinsically difficult to separate in the present study design. This limitation does not invalidate the observed association but suggests that the effect estimates should be interpreted as hypothesis-generating rather than strictly causal.
Future studies should therefore move beyond a simple comparison of SF and SD. A prospective multicenter study in which different securement methods are used within each participating institution would reduce institutional confounding. Ideally, randomization should occur at the patient level, with prespecified stratification according to access site, catheter type, number of lumens, and anticipated dwell time. In addition to dislocation and bloodstream infection, patient comfort, skin injury, nursing workload, cost, need for catheter replacement, and consequences of catheter failure should be considered. Such studies could ultimately identify predictors of mechanical and infectious complications and form the basis of a clinically useful securement algorithm.
Hong et al. [
1] have made an important contribution by demonstrating that catheter securement is not merely a procedural detail. Their findings reveal a clinically meaningful tension between mechanical stability and potential infection prevention and provide an opportunity to reconsider how CVC securement is selected. Rather than seeking a universally superior device, the next step should be to identify the optimal strategy for an individual clinical situation.
Thus, rather than asking simply “to tie or not to tie,” perhaps the more useful question is: Which securement strategy, for which catheter, in which patient? Answering this question may help transform CVC securement from a matter of institutional preference into an individualized component of vascular access management.
Conflict of interest
No potential conflict of interest relevant to this article was reported.
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Acknowledgments
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References
- 1. Hong JU, Kwon Y, Shim DJ, Lee JH. Securement of central venous catheters: suture fixation vs. stabilization devices in a multicenter retrospective study. Korean J Interv Radiol. 2026 Jul 27 [Epub]. https://doi.org/10.64961/kjir.2026.00123
- 2. Nickel B, Gorski L, Kleidon T, Kyes A, DeVries M, Keogh S, et al. Infusion therapy standards of practice, 9th edition. J Infus Nurs. 2024;47(1S):S1-S285. https://doi.org/10.1097/NAN.0000000000000532
- 3. Xu H, Hyun A, Mihala G, Rickard CM, Cooke ML, Lin F, et al. The effectiveness of dressings and securement devices to prevent central venous catheter-associated complications: a systematic review and meta-analysis. Int J Nurs Stud. 2024;149:104620. https://doi.org/10.1016/j.ijnurstu.2023.104620
- 4. Chen Y, Chen X, Jin X, Zeng X, Cao X, Zhao L. Compare the safety and efficacy of integrated securement device versus suture securement for centrally inserted central venous catheters: a prospective cohort study. Sci Rep. 2025;15:34907. https://doi.org/10.1038/s41598-025-18777-2
- 5. Templeton A, Schlegel M, Fleisch F, Rettenmund G, Schobi B, Henz S, et al. Multilumen central venous catheters increase risk for catheter-related bloodstream infection: prospective surveillance study. Infection. 2008;36:322-327. https://doi.org/10.1007/s15010-008-7314-x
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