Background
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. [1] Although venous cutdown has largely been replaced by the use of over-the-wire percutaneous catheters (also known as central lines), [2] it remains an excellent alternative when other approaches have failed.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] In pediatric patients, venipuncture may be rendered more difficult by nonvisible or nonpalpable peripheral veins. [6] For infants and children, however, cutdown has largely been replaced by intraosseous access as a secondary route of access and is only recommended when all other methods have failed.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 (GSV; also referred to as the greater or long saphenous vein) is the vessel most commonly used for the venous cutdown. [9, 10] Although the procedure can be performed at multiple sites along the length of the GSV, 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, [11, 12, 13] this vein's location distant from the primary resuscitative efforts centered on the head, neck, and torso affords unhindered access to the site.
Indications
Saphenous vein cutdown is indicated for the purpose of emergency venous access (when attempts to gain access via peripheral or percutaneous routes have failed).
Contraindications
Contraindications for saphenous vein cutdown include the following:
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Coagulopathy or bleeding diathesis
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Vein thrombosis
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Overlying cellulitis
Technical Considerations
Anatomy
The GSV, 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. [14]
At the ankle, the GSV passes approximately 2.5 cm anterior to the medial malleolus [15] 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 GSV courses anterolaterally through the fossa ovalis, where it joins the femoral vein approximately 4 cm below the inguinal ligament. (See the image below.)
Anatomic course of great saphenous vein.
The small saphenous vein (SSV; also referred to as the lesser or short saphenous vein) does not directly anastomose with the GSV. 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.
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Anatomic course of great saphenous vein.
