Intravenous (IV) access is one of the crucial first steps in the resuscitation of any critically ill or injured patient who presents to the emergency department (ED). When peripheral IV access fails, alternative routes must be sought to obtain rapid access for the purpose of infusing IV fluids, blood products, or medications.  Although the venous cutdown has largely been replaced by over-the-wire percutaneous catheters (also known as central lines)  , it remains an excellent alternative when other approaches have failed. 
The technique has been well described in the pediatric literature. [3, 4, 5] Venipuncture may be more difficult in pediatric patients secondary to nonvisible or nonpalpable peripheral veins.  In infants and children, however, the cutdown has largely been replaced by intraosseous access as a secondary route of access and is only recommended when all other methods have failed. [7, 8] For a comparison of vascular access methods, see Vascular Access Overview.
The great saphenous vein is the vessel most commonly used for the venous cutdown.  Although the procedure can be performed at multiple sites along the length of the vein, it is commonly performed at the ankle because the predictable and superficial location of the vein in this area allows it to be exposed with minimal dissection. Moreover, in the midst of resuscitation, its location distant from the primary resuscitative efforts centered on the head, neck, and torso affords unhindered access to the site.
Indications and contraindications
Saphenous vein cutdown is indication for the purpose of emergency venous access (when attempts to gain access via peripheral or percutaneous routes have failed).
Contraindications include the following:
Coagulopathy or bleeding diathesis
The great saphenous vein (also referred to as the greater or long saphenous vein), which is the longest vein in the body, originates at the ankle as a continuation of the medial marginal vein of the foot and ends at the femoral vein within the femoral triangle. At the ankle, it crosses 1 cm anterior to the medial malleolus and continues up the anteromedial aspect of the lower leg. It continues its superficial course and lies on the posteromedial aspect at the level of the knee. In the thigh, the great saphenous vein courses anterolaterally through the fossa ovalis, where it joins the femoral vein approximately 4 cm below the inguinal ligament. (See the image below.)
The small saphenous vein (also referred to as the lesser or short saphenous vein) does not directly anastomose with the great saphenous vein. It begins at the lateral aspect of the ankle and runs up the posterolateral lower leg to join the popliteal vein in the popliteal fossa.
Equipment used in saphenous vein cutdown includes the following:
Mask and sterile preparatory solution, gown, gloves, drape
Syringe, 5 mL, with a 25-gauge needle
Scalpel, No. 10 or No. 11 blade
Intravenous (IV) catheter (≥14 gauge)
Two silk ties, 3-0
Nylon suture, 4-0, on a cutting needle
Local anesthesia is used (1% lidocaine with or without epinephrine).
The patient is is placed in a supine position with the foot externally rotated. A tourniquet can be placed above the ankle but is not necessary.
Prepare the skin of the ankle with antiseptic solution (eg, povidone-iodine or chlorhexidine), and drape the area. Locate the vein 1 cm anterior and 1 cm superior to the medial malleolus. Anesthetize the skin over the area by infiltrating 1% lidocaine with or without epinephrine through a 25-gauge needle. (See Local Anesthetic Agents, Infiltrative Administration.)
Make a 2.5-cm full-thickness transverse skin incision over the site. With the curved hemostat, bluntly dissect the subcutaneous tissue parallel to the course of the great saphenous vein. Free the vein from its bed for a length of 2 cm.
With the curved hemostat, pass the ties underneath the exposed vein proximally and distally. Ligate the distal exposed vein, and leave the free ends of the tie in place for traction. Place traction on the proximal tie to further expose the vessel from its bed.
With the scalpel, perform a small transverse venotomy through no more than 50% of the total diameter of the vessel. Be extremely careful not to transect the vein fully. Introduce the plastic catheter through the venotomy opening, and secure it with the proximal tie. The opening of the venotomy site may be difficult to access; if so, try using a 20-gauge needle bent at a right angle as a vein elevator or dilator.
Attach intravenous (IV) tubing to the catheter. Alternatively, the IV tubing can be inserted directly into the venotomy site for more rapid flow rates. The distal tubing can be cut on a bevel for easier insertion into the opened vein.
Close the incision with simple interrupted sutures. Apply sterile dressing.
Potential complications of saphenous vein cutdown include the following:
Creation of a false passageway in the vessel wall