Brazilian Journal of Anesthesiology
Brazilian Journal of Anesthesiology
Systematic Review

Infraclavicular versus costoclavicular approaches to ultrasound-guided brachial plexus block: a systematic review and meta-analysis

Abordagens infraclaviculares versus costoclaviculares para bloqueio do plexo braquial guiado por ultrassom: uma revisão sistemática e meta-análise

Sara Texeira Amaral, Rafael Lombardi, Natalia Drabovski, Jeff Gadsden

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The costoclavicular approach to brachial plexus block may have a more favorable anatomy than the classic infraclavicular approach. However, there are conflicting results in the literature regarding the comparative effectiveness of these two techniques.


We systematically searched for Randomized Controlled Trials (RCTs) comparing costoclavicular with infraclavicular brachial plexus blocks for upper extremity surgeries on MEDLINE, EMBASE, and Ovid. The outcomes of interest were sensory and motor block onset times, performance times, block failure, and complication rate. We performed statistical analyses using RevMan 5.4 and assessed heterogeneity using the Cochran Q test and I2 statistics. We appraised the risk of bias according to Cochrane's Risk of Bias 2 tool.


We included 5 RCTs and 374 patients, of whom 189 (50.5%) were randomized to undergo costoclavicular block. We found no statistically significant differences between the two techniques regarding sensory block onset time in minutes (Mean Difference [MD = -0.39 min]; 95% CI -2.46 to 1.68 min; p = 0.71); motor block onset time in minutes (MD = -0.34 min; 95% CI -0.90 to 0.22 min; p = 0.23); performance time in minutes (MD = -0.12 min; 95% CI -0.89 to 0.64 min; p = 0.75); incidence of block failure (RR = 1.59; 95% CI 0.63 to 3.39; p = 0.63); and incidence of complications (RR = 0.60; 95% CI 0.20 to 1.84; p = 0.37).


This meta-analysis suggests that the CCV block may exhibit similar sensory and motor onset times when compared to the classic ICV approach in adults undergoing distal upper extremity surgery, with comparable rates of block failure and complications.


Brachial plexus block Nerve block Pain management Orthopedic procedures




A abordagem costoclavicular para bloqueio do plexo braquial pode ter anatomia mais favorável do que a abordagem infraclavicular clássica. No entanto, existem resultados conflitantes na literatura quanto à eficácia comparativa dessas duas técnicas.


Procuramos sistematicamente ensaios clínicos randomizados (ECR) comparando bloqueios do plexo braquial costoclavicular com infraclavicular para cirurgias de extremidades superiores no MEDLINE, EMBASE e Ovid. Os resultados de interesse foram tempos de início do bloqueio sensorial e motor, tempos de desempenho, falha do bloqueio e taxa de complicações. Realizamos análises estatísticas usando RevMan 5.4 e avaliamos a heterogeneidade usando o teste Cochran Q e estatística I2. Avaliamos o risco de viés de acordo com a ferramenta Risk of Bias 2 da Cochrane.


Incluímos 5 ECRs e 374 pacientes, dos quais 189 (50,5%) foram randomizados para serem submetidos ao bloqueio costoclavicular. Não encontramos diferenças estatisticamente significativas entre as duas técnicas em relação ao tempo de início do bloqueio sensorial em minutos (Diferença Média [DM = -0,39 min]; IC 95% -2,46 a 1,68 min; p = 0,71); tempo de início do bloqueio motor em minutos (DM = -0,34 min; IC 95% -0,90 a 0,22 min; p = 0,23); tempo de execução em minutos (DM = -0,12 min; IC 95% -0,89 a 0,64 min; p = 0,75); incidência de falha do bloqueio (RR = 1,59; IC 95% 0,63 a 3,39; p = 0,63); e incidência de complicações (RR = 0,60; IC 95% 0,20 a 1,84; p = 0,37).


Esta metanálise sugere que o bloqueio CCV pode apresentar tempos de início sensório e motor semelhantes quando comparado à abordagem ICV clássica em adultos submetidos à cirurgia distal da extremidade superior, com taxas comparáveis de falha do bloqueio e complicações.


Bloqueio do plexo braquial; Bloqueio nervoso; Controle da dor; Procedimentos ortopédicos


1. Stav A, Reytman L, Stav MY, et al. Comparison of the Supraclavicular, Infraclavicular and Axillary Approaches for UltrasoundGuided Brachial Plexus Block for Surgical Anesthesia. Rambam Maimonides Med J. 2016;7:e0013.

2. Tinoco J, Eloy A, Regufe R. Costoclavicular brachial plexus block: A review of current evidence. Rev Esp Anestesiol Reanim. 2022;69:649−53.

3. Chin KJ, Alakkad H, Adhikary SD, Singh M. Infraclavicular brachial plexus block for regional anaesthesia of the lower arm. Cochrane Database Syst Rev. 2013(8):CD005487.

4. Aliste J, Bravo D, Layera S, et al. Randomized comparison between interscalene and costoclavicular blocks for arthroscopic shoulder surgery. Reg Anesth Pain Med. 2019. https:// Online ahead of print.

5. Karmakar MK, Sala-Blanch X, Songthamwat B, Tsui BCH. Benefits of the costoclavicular space for ultrasound-guided infraclavicular brachial plexus block: description of a costoclavicular approach. Reg Anesth Pain Med. 2015;40:287−8.

6. Sala-Blanch X, Reina MA, Pangthipampai P, Karmakar MK. Anatomic Basis for Brachial Plexus Block at the Costoclavicular Space: A Cadaver Anatomic Study. Reg Anesth Pain Med. 2016;41:387−91.

7. Li JW, Songthamwat B, Samy W, Sala-Blanch X, Karmakar MK. Ultrasound-Guided Costoclavicular Brachial Plexus Block: Sonoanatomy, Technique, and Block Dynamics. Reg Anesth Pain Med. 2017;42:233−40.

8. García-Vitoria C, Vizuete J, Lopez Navarro AM, Bosch M. Costo-  clavicular Space: A Reliable Gate for Continuous Regional Anesthesia Catheter Insertion. Anesthesiology. 2017;127:712.

9. Silva GR, Borges DG, Lopes IF, Ruzi RA, Costa PRRDM, Mandim BLDS. Ultrasound-guided costoclavicular block as an alternative for upper limb anesthesia in obese patients. Braz J Anesthesiol. 2019;69:510−3.

10. Beh ZY, Hasan MS. Ultrasound-guided costoclavicular approach infraclavicular brachial plexus block for vascular access surgery. J Vasc Access. 2017;18:e57−61.

11. Ventura-Perez C, Leal-Gudino L, Luj ~ an Ure  no-y Prieto I, Ruiz- ~ Suarez M. Bloqueo de plexo braquial infraclavicular ecoguiado  comparando dos abordajes: coracoideo versus costoclavicular, evaluacion de la evid  encia cientí ^ fica. Rev Mex Anest. 2018; 41:117−23.

12. Moher D, Liberati A, Tetzlaff J, Altman DG, Group PRISMA. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6:e1000097.

13. Leurcharusmee P, Elgueta MF, Tiyaprasertkul W, et al. A randomized comparison between costoclavicular and paracoracoid ultrasound-guided infraclavicular block for upper limb surgery. Can J Anesth Can Anesth. 2017;64:617−25.

14. Songthamwat B, Karmakar MK, Li JW, Samy W, Mok LYH. Ultrasound-Guided Infraclavicular Brachial Plexus Block: Prospective Randomized Comparison of the Lateral Sagittal and Costoclavicular Approach. Reg Anesth Pain Med. 2018;43:825−31.

15. Brown B, Magsaysay P, Bureau Y, Yu J, Dhir S. Paracoracoid versus Costoclavicular Approach to Infraclavicular Block: A Prospective, Two Arm, Parallel Design, Single-Centre Randomized Controlled Trial. Anesthesia. 2020. 2020.10.03.20202275.

16. Cesur S, Yayik AM, Das AN. Ahiskalioglu A. A randomized com- ¸ parison between ultrasound-guided costoclavicular and infraclavicular block for upper extremity surgery. Turk J Med Sci. 2021;51:1883−8.

17. Dost B, Kaya C, Ustun YB, Turunc E, Baris S. Lateral Sagittal Versus Costoclavicular Approaches for Ultrasound-Guided Infraclavicular Brachial Plexus Block: A Comparison of Block Dynamics Through A Randomized Clinical Trial. Cureus. 2021;13:e141129.

18. Sterne JAC, Savovic J, Page MJ, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ. 2019;366:l4898.

19. Egger M, Davey Smith G, Schneider M, Minder C. Bias in metaanalysis detected by a simple, graphical test. BMJ. 1997; 315:629−34.

20. GRADEpro. Accessed October 16, 2022. https://www.gradepro. org/.

21. Nalini K, Bevinaguddaiah Y, Thiyagarajan B, Shivasankar A, Pujari V. Ultrasound-guided costoclavicular vs. axillary brachial plexus block: A randomized clinical study. J Anaesthesiol Clin Pharmacol. 2021;37:655.

22. Park SK, Lee SY, Kim WH, Park HS, Lim YJ, Bahk JH. Comparison of Supraclavicular and Infraclavicular Brachial Plexus Block: A Systemic Review of Randomized Controlled Trials. Anesth Analg. 2017;124:636−44.

23. Sotthisopha T, Elgueta MF, Samerchua A, et al. Minimum Effective Volume of Lidocaine for Ultrasound-Guided Costoclavicular Block. Reg Anesth Pain Med. 2017;42:571−4.

24. Layera S, Aliste J, Bravo D, et al. Single- versus double-injection costoclavicular block: a randomized comparison. Reg Anesth Pain Med. 2020;45:209−13.

25. Zhang L, Pang R, Zhang L. Comparison of ultrasound-guided costoclavicular and supraclavicular brachial plexus block for upper extremity surgery: a propensity score matched retrospective cohort study. Ann Palliat Med. 2021;10:454−61.

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