Venous cutdown

Venous cutdown is an emergency procedure in which the vein is exposed surgically and then a cannula is inserted into the vein under direct vision. It is used for venous access in cases of trauma, and hypovolemic shock when the use of a peripheral venous catheter is either difficult or impossible. The great saphenous vein is most commonly used. This procedure has fallen out of favor with the development of safer techniques for central venous catheterization such as the Seldinger technique, the modified Seldinger technique,[1][2][3] intraosseous infusion, as well as the use of ultrasound guidance for placement of central venous catheters without using the cutdown technique.[4][5][6]

Venous cutdown
ICD-9-CM38.94
MeSHD016748

Procedure

The skin is cleaned, draped, and anesthetized if time allows. The greater saphenous vein is identified on the surface above the medial malleolus, a full-thickness transverse skin incision is made, and 2 cm of the vein is freed from the surrounding structures. The vessel is tied closed distally, the proximal portion is transected (venotomy) and gently dilated, and a cannula is introduced through the venotomy and secured in place with a more proximal ligature around the vein and cannula. An intravenous line is connected to the cannula to complete the procedure.

Complications

Complications of venous cutdown include cellulitis, hematoma, phlebitis, perforation of the posterior wall of the vein, venous thrombosis and nerve and arterial transection. This procedure can result in damage to the saphenous nerve due to its intimate path with the great saphenous vein, resulting in loss of cutaneous sensation in the medial leg. Over the years, the venous cutdown procedure has become outdated by the introduction and recent prehospital developments of intraosseous infusion in trauma/hypovolemic shock patients.

References
  1. Seldinger SI: Catheter replacement of the needle in percutaneous arteriography. Acta Radiol 1953; 39:368-376
  2. McGee WT, Mallory DL: Cannulation of the internal and external jugular veins. In: Vascular Cannulation. Problems in Critical Care. Vol. 2. Venus B, Mallory DL (Eds). Philadelphia, PA, JB Lippincott, 1988, pp 217-241
  3. Brahos GJ, Cohen MJ: Supraclavicular central venous catheterization. Techniques and experience in 250 cases. Wisc Med J 1981; 80:36-38
  4. Teichgraber UK, Benter T, Gebel M, et al: A sonographically guided technique for central venous access. AJR Am J Roentgenol 1997; 169:731-733
  5. Randolph AD, Cook DJ, Gonzales CA, et al: Ultrasound guidance for placement of central venous catheters: A meta-analysis of the literature. Crit Care Med 1996; 24:2053-2058
  6. Sabba JA, Hedges JR: Ultrasonographic guidance for internal jugular vein cannulation: An educational imperative; a desirable practice alternative. Ann Emerg Med 2006; 48:548-550

Notes
  • McIntosh B, Dulchavsky S (1992). "Peripheral vascular cutdown". Crit Care Clin. 8 (4): 807–18. doi:10.1016/S0749-0704(18)30226-4. PMID 1393752.
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