Saphenous Vein Cutdown


Article Author:
Mary Lee


Article Editor:
Joshua Loyd


Editors In Chief:
Dustin Constant
Donald Kushner


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Trevor Nezwek
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
6/18/2019 2:41:50 AM

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 draws. [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 useful alternative in an acute setting.[2][3][4]

Anatomy

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 
  • Intravenous (IV) drug abusers
  • 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
  • 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 fluid bag and tubing

Personnel

Greater saphenous vein 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 larger IV tubing 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 catheter tightly. The distal vein is also ligated with a silk suture. The catheter 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]


Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Saphenous Vein Cutdown - Questions

Take a quiz of the questions on this article.

Take Quiz
Where is a cut down on the saphenous vein done?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What is the most common vessel that is cut down for intravenous access?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
During a saphenous vein cutdown just above the medial side of the ankle, the patient starts to complain of numbness and a tingling sensation. The cause of this is related to injury of which nerve?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 9-year old male who has been brought in by emergency medical services (EMS) following a drowning incident. The child was intubated at the site and there is no intravenous access. You have been asked to quickly perform a saphenous vein cutdown. At which site in the leg is this usually accomplished?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Anatomically where is the saphenous vein cannulated at the ankle?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Saphenous Vein Cutdown - References

References

Ker K,Tansley G,Beecher D,Perner A,Shakur H,Harris T,Roberts I, Comparison of routes for achieving parenteral access with a focus on the management of patients with Ebola virus disease. The Cochrane database of systematic reviews. 2015 Feb 26;     [PubMed]
Cole I,Glass C,Norton HJ,Tayal V, Ultrasound measurements of the saphenous vein in the pediatric emergency department population with comparison to i.v. catheter size. The Journal of emergency medicine. 2012 Jul;     [PubMed]
Chappell S,Vilke GM,Chan TC,Harrigan RA,Ufberg JW, Peripheral venous cutdown. The Journal of emergency medicine. 2006 Nov;     [PubMed]
Taghizadeh R,Gilbert PM, Long saphenous venous cutdown revisited. Burns : journal of the International Society for Burn Injuries. 2006 Mar;     [PubMed]
Toro A,Sofia M,Sparatore F,Lombardo R,Cordio S,Di Carlo I, [Assessment of patient's comfort and functioning of a totally implantable venous system placed in the safenous vein]. Il Giornale di chirurgia. 2005 Jun-Jul;     [PubMed]
Campanella LM,Bloch H,Gang M,Rennie W,Ort V, A review of clinically relevant human anatomy in emergency medicine. The Journal of emergency medicine. 2005 Oct;     [PubMed]
Haas NA, Clinical review: vascular access for fluid infusion in children. Critical care (London, England). 2004 Dec;     [PubMed]
Custalow CB,Kline JA,Marx JA,Baylor MR, Emergency department resuscitative procedures: animal laboratory training improves procedural competency and speed. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 2002 Jun;     [PubMed]
Klofas E, A quicker saphenous vein cutdown and a better way to teach it. The Journal of trauma. 1997 Dec;     [PubMed]
Hubble MW,Trigg DC, Training prehospital personnel in saphenous vein cutdown and adult intraosseous access techniques. Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors. 2001 Apr-Jun;     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Surgery-Podiatry Cert Medicine. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Surgery-Podiatry Cert Medicine, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Surgery-Podiatry Cert Medicine, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Surgery-Podiatry Cert Medicine. When it is time for the Surgery-Podiatry Cert Medicine board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Surgery-Podiatry Cert Medicine.