Saphenous Vein Cutdown
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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 [1] Although venous cutdown has largely been replaced by the use of over-the-wire percutaneous catheters (also known as central lines) [2] , it remains an excellent alternative when other approaches have failed.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] Venipuncture may be more difficult in pediatric patients secondary to nonvisible or nonpalpable peripheral veins. [6] In infants and children, however, cutdown has largely been replaced by intraosseous access as a secondary route of access and is only recommended when all other methods have failed.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) is the vessel most commonly used for the venous cutdown. [9] 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, [10, 11, 12] this vein’s location distant from the primary resuscitative efforts centered on the head, neck, and torso affords unhindered access to the site.
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 for saphenous vein cutdown include the following:
The GSV (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. [13]
At the ankle, the GSV 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 GSV 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 (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.
Chappell S, Vilke GM, Chan TC, Harrigan RA, Ufberg JW. Peripheral venous cutdown. J Emerg Med. 2006 Nov. 31(4):411-6. [Medline].
Boon JM, van Schoor AN, Abrahams PH, Meiring JH, Welch T, Shanahan D. Central venous catheterization — an anatomical review of a clinical skill — Part 1: subclavian vein via the infraclavicular approach. Clin Anat. 2007 Aug. 20(6):602-11. [Medline].
Adelman S. An emergency intravenous route for the pediatric patient. JACEP. 1976 Aug. 5(8):596-8. [Medline].
Gauderer MW. Vascular access techniques and devices in the pediatric patient. Surg Clin North Am. 1992 Dec. 72(6):1267-84. [Medline].
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. J Emerg Med. 2012 Jul. 43 (1):87-92. [Medline].
King D, Conway EE Jr. Vascular access. Pediatr Ann. 1996 Dec. 25(12):693-8. [Medline].
Asaravala M, Kharasch M, Pettineo C, Vozenilek JA, Wang EE. Emergent intraosseous access. Acad Emerg Med. 2008 Dec. 15 (12):1324. [Medline].
de Caen A. Venous access in the critically ill child: when the peripheral intravenous fails!. Pediatr Emerg Care. 2007 Jun. 23(6):422-4; quiz 425-6. [Medline].
Taghizadeh R, Gilbert PM. Long saphenous venous cutdown revisited. Burns. 2006 Mar. 32(2):267-8. [Medline].
American College of Surgeons. Advanced Trauma Life Support Student Course Manual. 9th ed. Chicago: American College of Surgeons; 2012.
Chameides L, Samson RA, Schexnayder SM, Hazinski MF, eds. Pediatric Advanced Life Support: Provider Manual. Dallas, TX: American Heart Association/American Academy of Pediatrics; 2012.
Roberts JR. Roberts and Hedges’ Clinical Procedures in Emergency Medicine. 6th ed. Philadelphia: WB Saunders; 2013.
Gray H. Anatomy of the Human Body: VII. The veins. 3d. The veins of the lower extremity, abdomen, and pelvis. Bartleby.com. Available at http://www.bartleby.com/107/173.html. Accessed: May 18, 2017.
Ker K, Tansley G, Beecher D, Perner A, Shakur H, Harris T, et al. Comparison of routes for achieving parenteral access with a focus on the management of patients with Ebola virus disease. Cochrane Database Syst Rev. 2015 Feb 26. CD011386. [Medline]. [Full Text].
Matthew A Silver, MD Staff Physician, Department of Emergency Medicine, Kaiser Permanente, San Diego Medical Center; Voluntary Clinical Instructor, University of California, San Diego, School of Medicine
Matthew A Silver, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Phi Beta Kappa, Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Nothing to disclose.
Luis M Lovato, MD Associate Clinical Professor, University of California, Los Angeles, David Geffen School of Medicine; Director of Critical Care, Department of Emergency Medicine, Olive View-UCLA Medical Center
Luis M Lovato, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Vincent Lopez Rowe, MD Professor of Surgery, Program Director, Vascular Surgery Residency, Department of Surgery, Division of Vascular Surgery, Keck School of Medicine of the University of Southern California
Vincent Lopez Rowe, MD is a member of the following medical societies: American College of Surgeons, American Surgical Association, Pacific Coast Surgical Association, Society for Clinical Vascular Surgery, Society for Vascular Surgery, Western Vascular Society
Disclosure: Nothing to disclose.
Andrew K Chang, MD, MS Vincent P Verdile, MD, Endowed Chair in Emergency Medicine, Professor of Emergency Medicine, Vice Chair of Research and Academic Affairs, Albany Medical College; Associate Professor of Clinical Emergency Medicine, Albert Einstein College of Medicine; Attending Physician, Department of Emergency Medicine, Montefiore Medical Center
Andrew K Chang, MD, MS is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American Academy of Pain Medicine, American College of Emergency Physicians, American Geriatrics Society, American Pain Society, Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Louis Gelabert, PA Physician Assistant, Emergency Department, Montefiore Medical Center
Louis Gelabert, PA is a member of the following medical societies: American Academy of Physician Assistants
Disclosure: Nothing to disclose.
Saphenous Vein Cutdown
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