The Journal of Emergency Medicine, Vol. 31, No. 4, pp.

411– 416, 2006

Copyright © 2006 Elsevier Inc.
Printed in the USA. All rights reserved
0736-4679/06 $–see front matter

doi:10.1016/j.jemermed.2006.05.026

Technical
Tips

PERIPHERAL VENOUS CUTDOWN

Stephen Chappell, MD,* Gary M. Vilke, MD,† Theodore C. Chan, MD,† Richard A. Harrigan, MD,* and
Jacob W. Ufberg, MD*
*Department of Emergency Medicine, Temple University School of Medicine, Philadelphia, Pennsylvania, and †Department of
Emergency Medicine, University of California, San Diego Medical Center, San Diego, California
Reprint Address: Jacob W. Ufberg, MD, Department of Emergency Medicine, Temple University School of Medicine, 3401 N. Broad
St., 10th Floor Jones Hall, Philadelphia, PA 19004

e Abstract—Timely establishment of vascular access is a tients with shock (1). Saphenous vein cutdown, which
critical component of the care of the acutely ill or injured had long been the mainstay of venous access in the
patient. Peripheral venous cutdown, once a mainstay in the trauma patient, is now infrequently utilized. This is due
care of the severely traumatized patient, has progressively in large part to the introduction of the Seldinger tech-
lost favor since the introduction of the Seldinger technique
nique for percutaneous access and the declining number
of central venous line placement. In fact, recent editions of
the Advanced Trauma Life Support (ATLS) text refer to
of residents being taught proper cutdown techniques. The
saphenous venous cutdown as an optional skill to be taught sixth edition of the Advanced Trauma Life Support
at the discretion of the instructor. In certain patients, per- (ATLS) text refers to the saphenous vein cutdown as an
cutaneous vascular access may be impossible to achieve or optional skill to be taught at the discretion of the instruc-
result in unacceptable time delays. In these situations, the tor (2). Although percutaneous femoral venous catheter-
ability to rapidly and proficiently perform peripheral ve- ization using the Seldinger technique has essentially re-
nous cutdown techniques may prove invaluable and poten- placed peripheral venous cutdown techniques, situations
tially lifesaving. This article reviews the anatomy of the occur during which venous cutdown is indicated and
most common sites used for peripheral venous cutdown, may prove life-saving.
peripheral venous cutdown techniques, and the complica-
Percutaneous vascular access in certain situations and
tions associated with peripheral venous cutdown. © 2006
Elsevier Inc.
patient populations may be impossible or result in unac-
ceptable time delays. Patients with profound hemor-
e Keywords—peripheral venous cutdown; venous cut- rhagic shock, asystole, or pulseless electrical activity will
down; vascular access; resuscitation lack palpable femoral arterial pulses, complicating fem-
oral venous access. The intravenous drug user or exten-
sively injured patient without identifiable peripheral
INTRODUCTION veins or scarred, anatomically altered central venous
access sites may be equally challenging. It is among
Vascular access is of critical importance in the resusci- these patients that proficiency in peripheral venous cut-
tation of the acute medical or trauma patient. Peripheral down techniques may prove invaluable and why it
venous cutdown techniques were first described by should remain within the emergency physician’s proce-
Keely in 1940 as an alternative to venipuncture in pa- dural armamentarium.

Technical Tips is coordinated by Gary M. Vilke, MD, of the University of California, San Diego, San Diego, California
and Richard A. Harrigan, MD, and Jacob W. Ufberg, MD, of Temple University, Philadelphia, Pennsylvania
RECEIVED: 14 March 2006;
ACCEPTED: 9 May 2006
411
412 S. Chappell et al.

to the pubic tubercle after passing over the falciform

margin of the deep investing fascia.
Generally, the portion of the saphenous vein in the
groin is preferred for cutdown due to its large diameter
and comparative ease of dissection at this level. It easily
allows the introduction of an 8.5 French cordis, which is
ideal for rapid resuscitation with either crystalloid or
blood. It traverses the anteromedial thigh superficial to
the femoral artery and vein, entering the fossa ovalis to
join the femoral vein. It can be located 4 cm inferior and
3 cm lateral to the pubic tubercle or approximately 2 cm
inferior to the site that would be used for percutaneous
femoral line placement. Another described approximate
landmark is just distal to where the scrotal or labial fold
meets the thigh (Figure 1).
With a #10 scalpel, a transverse incision is made from
just distal to where the labial/scrotal fold meets the thigh.
The incision is extended laterally for 5– 6 cm, entering
the subcutaneous tissues (Figure 2). Dissection through
the subcutaneous tissues may be performed with hemo-
stats. A more expeditious dissection can be accomplished
with manual blunt dissection (Figure 3). If the thigh
muscles or deep investing fascia are encountered, the
dissection is too deep. Landmarks should be relocated
and the skin incision/dissection adjusted as needed. An-
other technique, described by Rogers, involves similar
Figure 1. Shown is the site for incision to locate the greater
saphenous vein proximally in the groin. Note the medial blunt manual dissection but through an incision made
aspect of the incision starts where the labial fold meets the parallel to the vessel (3). He described making a 10-cm
thigh. incision from 2 fingerbreadths lateral and inferior to the
pubic tubercle extended in the direction of the medial
ANATOMY epicondyle of the femur. The dissection is accomplished
by grasping the skin edges and forcibly pulling them
There are three primary areas at which venous cutdown apart, readily revealing the vein’s course along the ante-
can be performed. The greater saphenous vein proxi-
mally in the groin and distally at the ankle, and the
basilic vein above the elbow. The anatomic location of
each of these vessels will first be discussed followed by
the various cannulation techniques that can be applied at
each location.

Greater Saphenous Vein

The greater saphenous vein is the longest vein in the

body, and its superficial location and anatomic regu-
larity make it ideal for cutdown. The saphenous vein
arises from the dorsal venous arch of the foot. It
ascends cephalad approximately 2 cm anterior to the
medial malleolus. Two centimeters cephalad to the
medial malleolus, it lies just anterior to the tibial
periosteum. Along with the saphenous nerve it contin- Figure 2. The incision is made from where the labial or
ues to ascend within the superficial fascia along the scrotal fold meets the thigh medially and extended 6 cm
laterally. Applying traction on the skin perpendicular to the
medial aspect of the leg. It eventually joins the fem- incision facilitates dissection through the skin and superfi-
oral vein approximately 4 cm below and 3 cm lateral cial subcutaneous tissue only.
Peripheral Venous Cutdown 413

Figure 3. With the assistance of 4 ⴛ 4 gauze, the skin edges

are grasped and spread apart perpendicular to the direction
of the incision. This motion may likely need to be repeated
several times, extending the dissection deeper into the sub-
cutaneous tissues until the saphenous vein is revealed.
These forces are applied parallel to the course of the vein Figure 5. The vein can be located approximately 2 finger-
and will not damage the vessel. breadths cephalad and superior to the medial epicondyle.
Dependent upon body habitus, the groove between the bi-
ceps and triceps muscle can be used as a landmark. The
location for incision is demonstrated here.
rior thigh to the saphenofemoral junction. The only de-
scribed disadvantage is the length of the incision.
At the level of the ankle, the saphenous vein may be With tips facing down, a curved hemostat is inserted
readily found and isolated. With the leg extended and along the posterior border of the tibia. It is then moved
externally rotated, locate the medial malleolus (Figure anteriorly along the flat surface of the tibia to free the
4). While applying counter-traction on the skin in a overlying tissue from the periosteum below. Rotating the
direction perpendicular to the incision, a 3-cm incision is hemostat tips along the perisoteum upward and spread-
made using a #10 scalpel across the flat tibial surface. ing the jaws will free the saphenous vein and nerve from
The incision should be through the skin but not deep into the surface of the tibia. Alternatively, a quick method of
subcutaneous tissue, as the vein is often superficial and isolating the saphenous vein is to introduce a mosquito
can be easily transected by an overly aggressive incision. clamp at the medial border of the incision just cephalad
to the medial malleolus. The mosquito is pushed down-
wards to the periosteum of the bone, and then resurfaces
just medial to the anterior tibialis tendon. When the tips
of the clamp are spread, the vein lies on the clamp.

Basilic Vein

Although the greater saphenous is preferred because its

dissection does not interfere with concurrent resuscitative
efforts, it may not be amenable to cutdown secondary to
lower extremity amputation, deformity, or trauma. In these
instances, the basilic vein may be accessed by cutdown. The
arm should be abducted 90 degrees, flexed at 90 degrees,
and externally rotated with the palm facing upwards. Using
a #10 scalpel, a 3-cm incision is made on the medial portion
of the arm 2 cm proximal and 2–3 cm lateral to the medial
Figure 4. The greater saphenous in the ankle is found 2 epicondyle (Figure 5). The incision should be superficial,
fingerbreadths cephalad to the medial malleolus. The inci-
sion should be superficial and span the width of the tibia, for just revealing the underlying subcutaneous tissue. Using the
the vessel lies just anterior to the tibial periosteum. blunt manual dissection techniques, the basilic vein should
414 S. Chappell et al.

citation may then begin after securing the cordis to the skin.
With the smaller venotomy compared to the classic tech-
nique, ligation of the distal end of the vessel to prevent
bleeding is rarely necessary. The dissection incision may be
sutured closed around the cordis or covered with a large
dressing after placing moist gauze in the incision. When
compared to the classic technique, the modified Seldinger
technique is 22% (an average of 2 min and 13 s) faster (4).
This increased speed is due to the elimination of the steps
involving ligation of the distal vein and securing the cordis
with a second ligature.

Classic Technique

Figure 6. The curved hemostat is used to elevate the vein After isolation, the desired vein can be elevated from the
and allow it to become distended with blood. The scalpel surrounding adipose/subcutaneous tissue by placing a
blade is then inserted through both lateral vessel walls,
traversing only 1–2 mm of the anterior vessel wall. This will curved hemostat underneath it. Next, 0 Vicryl suture is
prevent transecting the vessel or cutting the posterior wall. passed underneath the vessel at the furthest proximal/distal
Gently moving the blade anteriorly and toward the distal end points that the incision permits. Slight upward tension is
of the vessel creates the venotomy.
placed on the suture to occlude venous flow. This may be

emerge. The dissection is too deep if the brachial artery,

median nerve, or muscle bellies are encountered.

TECHNIQUES FOR VEIN CANNULATION

There exist several techniques for vein cannulation after

its isolation. Two will be discussed below. For either of
the techniques described below, the vein may be cannu-
lated with a smaller-bore cannula than the 8.5 French
cordis described if the vessel is found to be too small to
accommodate a trauma cordis (this may occur particu-
larly when using the saphenous vein at the ankle). Ad-
ditionally, sutures may be passed below the vessel prox-
imally and distally to provide traction on the vessel or to
elevate it before venotomy. Some authorities advocate
tying the distal suture to ligate the vessel distally.

Modified Seldinger Technique

After isolation of the desired vein, it can be elevated from

the surrounding adipose/subcutaneous tissue by placing a
curved hemostat underneath it. A venotomy is then created
in a horizontal direction, parallel to the plane of the patient
using an #11 scalpel (Figure 6). With the venotomy created,
Figure 7. The wire (straight end first) in the dilatator and the
the wire (straight end first) within the dilatator, within the cordis is then inserted into the venotomy. The dilatator and
cordis is then passed into the venotomy (Figure 7). The cordis can then be advanced in tandem over the wire into the
dilatator and cordis can then be advanced over the wire into vein. Twisting the cordis/dilatator combination while ad-
vancing facilitates their passage. With the cordis/dilatator
the vein. When the cordis has been advanced to the hub, the advanced to the hub, the dilatator and wire may be removed.
wire and dilatator may be removed simultaneously. Resus- The cordis can then be secured by suturing to the skin.
Peripheral Venous Cutdown 415

accomplished by hemostats or by an assistant. By occluding

the vein at its proximal end first, this will make it more
distended with blood facilitating venotomy. A venotomy is
created as described earlier in the modified Seldinger tech-
nique section. The venotomy created will need to be larger
when employing this technique to facilitate passage of the
dilatator and cordis without the guidewire used in the mod-
ified Seldinger technique. The dilatator and cordis in tan-
dem are inserted through the venotomy as tension is grad-
ually released on the proximal suture to permit dilatator/
cordis passage through the lumen. This proximal suture is
then tied snugly around the vessel and cordis before re-
moval of the dilatator. This prevents inadvertent narrowing/
occlusion of the cordis lumen by tying the suture too tight.
The distal suture may be used to ligate the vessel distally.
The cordis should then be sutured to the skin. With the
dilatator removed, the cordis may then be connected to IV
tubing and volume resuscitation begun.

Alternatives to the 8.5 French Cordis Using the

Classic Technique

On some occasions, the vein has been isolated and seems

to be too small to accommodate an 8.5 French cordis.
This may be especially true when gaining access to the
saphenous vein at the ankle. When this occurs, a large- Figure 8. Displayed above is the use of a vein pick to facili-
tate the placement of a standard angiocatheter. The vein
bore angiocatheter (with the needle removed) may be pick is used to hold the venotomy open when using the
placed through the venotomy using the classic technique classic technique.
and secured in the same fashion as described above. A
vein pick may facilitate the placement of a standard
angiocatheter using the classic technique by holding the or aberrant anatomy at the cutdown site are relative contra-
venotomy open for placement of the angiocather (Figure indications. One of the common complications of dissection
8). Alternatively, the venotomy may be omitted and the in the area and saphenous vein cutdown in the groin is
angiocatheter can be placed into the intact vein in the injury of the femoral vein or artery with large and obscuring
same fashion as percutaneous IV placement. hemorrhage. If this occurs, the safest solution is to pack the
In the event that large-bore access is needed and an area, use the opposite extremity, and explore the groin in the
8.5 French cordis is not available, standard IV tubing operating room to repair the large vessels safely. Other
may be used. The end of the tubing is cut at a 45-degree complications include wound infection, wound dehiscence,
angle, and the air is flushed out of the tubing. The thromboembolism, phlebitis, hematoma formation, and
now-beveled end of the tubing may be slipped directly nerve injury. The incidence of complications has been re-
through the venotomy using the classic technique. The ported to be between 2% and 15% (5,6). Arterial, venous,
vein can be sutured around the catheter proximally, and and nerve injury may be avoided by a knowledge of the
fluid resuscitation may begin. surrounding anatomy and technical proficiency in the var-
ious cutdown techniques. The other complications may be
markedly reduced or eliminated altogether by removal of
Contraindications and Complications for Peripheral the catheter within 12 h after placement.
Venous Cutdown

Absolute contraindications to peripheral venous cutdown Conclusion

are major blunt or penetrating trauma to the extremity on
which the procedure is to be performed or vascular injury In the trauma or medical patient in extremis, vascular access
proximal to the cutdown site in the extremity. Skin/soft is essential during the resuscitative efforts. Oftentimes,
tissue infection at the cutdown site, coagulation disorders, body habitus, past medical history, or clinical circumstances
416 S. Chappell et al.

make peripheral or central percutaneous intravenous access 2. American College of Surgeons. Advanced trauma life support for
challenging. It is in these situations that knowledge of the doctors: student course manual, 6th edn. Chicago, IL: American
College of Surgeons; 1997.
anatomy and technique for peripheral venous cutdown may 3. Rogers FB. Technical note: a quick and simple method of obtaining
prove life-saving. Although these techniques may be relied venous access in traumatic exsanguination. J Trauma 1993;34:
upon infrequently, emergency physicians should be familiar 142–3.
4. Shockley LW, Butzier DJ. A modified wire-guided technique for
with how they are performed. venous cutdown. Ann Emerg Med 1990;19:393– 4.
5. Rhee KJ, Derlet RW, Beal SL. Rapid venous access using sa-
phenous vein cutdown at the ankle. Am J Emerg Med 1988;7:
REFERENCES 263– 6.
6. Moran JM, Atwood RP, Rowe MI. A clinical and bacteriological
1. Keeley JL. Intravenous injections and infusions. Am J Surg 1940; study of infections associated with venous cutdowns. N Engl J Med
50:485–90. 1965;272:545– 60.