Saphenous Vein Cutdown 

Intravenous access is one of the crucial first steps in the resuscitation of any critically ill or injured patient who presents to the emergency department. When peripheral intravenous access fails, alternative routes must be sought to obtain rapid access for the purpose of infusing intravenous fluids, blood products, or medications.^[1] Although the venous cutdown has largely been replaced by over-the-wire percutaneous catheters (also known as central lines)^[2] , it remains an excellent alternative when other approaches have failed.^[1]

The technique has been well described in the pediatric literature,^{[3, 4, 5]} where venipuncture may be more difficult secondary to nonvisible or nonpalpable peripheral veins.^[6] In infants and children, however, the cutdown has largely been replaced by intraosseous access as a secondary route of access and is only recommended when all other methods have failed.^{[7, 8]} For a comparison of vascular access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 eMedicine article Vascular Access: Surgical Perspective.

The greater saphenous vein is the most common vessel used for the venous cutdown.^[9] Although the procedure can be performed at multiple sites along the length of the saphenous 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 at the head, neck, and torso allow for unhindered accessibility to the site.

Anatomy

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 greater 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 lesser saphenous vein, also known as the short saphenous vein, does not directly anastomose with the greater 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.

• Emergent venous access (when attempts to gain access by the peripheral or percutaneous routes have failed)

• Coagulopathy or bleeding diathesis
• Vein thrombosis
• Overlying cellulitis

• Local anesthesia is used (1% lidocaine with or without epinephrine).
• See Technique for details.

• Mask and sterile preparatory solution, gown, gloves, drape
• Gauze pads
• Syringe, 5 mL, with a 25-gauge (ga) needle
• Scalpel, No. 10 or No. 11 blade
• Curved hemostat
• Scissors
• Intravenous catheter (≥14 ga)
• Intravenous tubing
• Two silk ties, 3-0
• Nylon suture, 4-0, on a cutting needle
• Tourniquet (optional)

• Position the patient supine 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 [Betadine, Povidine], chlorhexidine [Hibiclens]), and drape the area.
• Locate the vein 1 cm anterior and 1 cm superior to the medial malleolus.
• Anesthetize the skin over the area with 1% lidocaine with or without epinephrine and a 25-gauge needle. For more information, 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 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.
• Pull 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 to not fully transect the vein.
• Introduce the plastic catheter (≥14 ga) through the venotomy opening, and secure it with the proximal tie.
• Attach intravenous tubing to the catheter, and close the incision with simple interrupted sutures.
• Apply sterile dressing.

• Intravenous 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.
• The opening of the venotomy site may be difficult to access. Try using a 20-ga needle bent at a right angle as a vein elevator or dilator.

• Failed cannulation
• Creation of a false passageway in the vessel wall
• Hemorrhage
• Air embolus
• Venous thrombosis
• Infection
• Nerve transection
• Artery transection