Introduction

The establishment of venous access is essential to the treatment and resuscitation of both the medically and traumatically ill patient.  Adequate venous access allows the delivery of fluids, blood products, medications, and repeated blood sampling. [1]

The venous cutdown technique is a surgical procedure to gain venous access when relatively less invasive percutaneous procedures such as the Seldinger technique (percutaneous access), ultrasound-guided venous access, and intraosseous vascular access have failed. Percutaneous access can be difficult to achieve in certain patient populations (pediatric patients with small and nonpalpable veins, patients in hypovolemic shock with collapsed veins, patients with peripheral vascular disease with altered vascular anatomy) making venous cutdown a life-saving alternative.[2][3][4]

Anatomy and Physiology

The greater saphenous vein (GSV) is the longest vein in the body and is the most common site for venous cutdown. It is part of the superficial venous collecting system of the lower extremity originating in the foot and traveling up the medial leg and upper thigh where it enters the femoral vein within the femoral triangle. Specifically, at the foot, it originates at the confluence of the dorsal vein of the first digit and the dorsal venous arch of the foot. It travels up the medial leg alongside the saphenous nerve which must be preserved during vein harvesting. At the knee, it runs over the posterior border of the medial condyle of the femur bone. It takes a slightly lateral course along the anteromedial thigh before entering an opening in the fascia lata called the saphenous opening at the saphenofemoral junction. Anatomic consistency and its superficial location at the ankle anterior to the medial malleolus make the GSV an ideal target vessel for cutdown allowing rapid access and minimal dissection. It is also the most commonly used conduit for cardiovascular bypass operations.

Indications

A venous cutdown is indicated when percutaneous venous access is unsuccessful. Furthermore, cutdown is often indicated in:

• Infants, children, and adults in shock 
• Burned or scarred patients
• Distorted anatomy
• Cardiac arrest without a palpable femoral pulse
• Individuals in which IV lines or alternative techniques for obtaining central access cannot be quickly obtained
• Intravenous (IV) drug abusers where all the peripheral veins are thrombosed
• Vascular lower extremity bypass operations (femoral-popliteal or femoral-distal bypass) requiring a vein conduit
• Vascular operations requiring a vein patch

Contraindications

A cutdown is contraindicated when there is trauma to the targeted site or in patients with a massive pelvic injury with suspected avulsion of the iliac veins. Cutdown should not be performed when there is an active infection over the site of interest, when coagulopathies are present, or when less-invasive methods of venous access are possible. In the event of bilateral lower extremity trauma compromising the integrity of the GSV, the basilic vein in the upper extremity may be an alternative access site.

Equipment

• Skin Prep solution: Povidone-iodine or chlorhexidine
• Personal protective equipment: Gown, mask, eye protection, sterile gloves
• Scalpel
• Silk suture ties
• Curved hemostats or right angle 
• Smooth pickups
• IV cannula
• IV fluid bag and tubing
• Adhesive tape for the skin

Personnel

GSV cut down can be performed by a trained surgeon or trained medical professional such as a surgery resident, emergency medicine resident or midlevel provider. In an ideal situation, the operator will have an assistant to hand instruments, materials and IV tubing. In an acute trauma setting, collaborative effort is made by the trauma surgeon, emergency room (ER) physician and nurse to establish IV access and resuscitate the patient.

Preparation

A local anesthetic (lidocaine 1% or 2% with or without epinephrine) may be administered before skin incision depending on the acuity of the situation and status of the patient. Try to palpate the saphenous vein anterior to the medial malleolus (harder to locate in patients with hypovolemic shock). Have all equipment open and available before making the skin incision.

Technique

The cutdown procedure begins with sterile preparation and draping of the anteromedial ankle with the medial malleolus visible as a bony landmark. Traveling 1 cm anterior and 1 cm superior to the medial malleolus approximates the location of the GSV where a 3 cm transverse skin incision is made with a scalpel. Curved hemostats are then used to longitudinally dissect through the subcutaneous tissue while being cognizant of the rather superficial location of the vessel. Dissection continues circumferentially around the vessel and extends a length of about 2 cm to allow passage of permanent suture material such as 3-0 silk around the proximal and distal ends of the exposed vessel. Care must be taken to dissect off and avoid damage to the saphenous nerve which runs parallel with the vein. These sutures will aid in proximal and distal control as well as act as a sling to gently lift the vessel into the surgical field. A hemostat may be used to apply distal traction in preparation for venous entry. Venous access is gained by either a formal venotomy with a No. 15 scalpel to accommodate a larger IV cannula or by an introducer needle using Seldinger technique. If using a scalpel, place a hemostat behind the mobilized vein to aid in dividing 40% of the transverse diameter. Importantly, this venous access is secured by tying down the permanent suture encircling both the vein and cannula hub tightly. The distal vein is also ligated with a silk suture. The cannula or IV tubing should also be secured to the skin with suture or tape to prevent it from being dislodged.

Complications

Potential complications of the venous cutdown technique include infection, failed cannulation, hemorrhage, nerve injury, and air embolism. Removal of the catheter within 12 to 24 hours is recommended to reduce the incidence of complications.

Clinical Significance

Greater saphenous vein cutdown technique remains an effective intervention for rapid venous access in the case of failed percutaneous methods. Its remote location from the head and torso make GSV cutdown at the ankle feasible during major resuscitation efforts, especially in the acute traumatic setting.[5][6][7][8]

Enhancing Healthcare Team Outcomes

Saphenous vein cutdown requires a skilled operator with knowledge of vascular anatomy. Often this procedure is performed in the trauma bay where a team of ER physicians, trauma surgeons, and nurses work collaboratively to resuscitate the acutely ill patient. There are no published RCTs that confirm or refute the positive influence of a coordinated health care team on the success of the vein cutdown technique.[9][10]