Overview of Saphenous Vein Cutdown
Establishing a pathway into a patient’s veins is a crucial step in treating and helping both patients with medical conditions and those with injuries. This channel into the veins lets doctors deliver fluids, blood products, and medications into the body. It also allows for the regular collection of blood samples for testing.
The venous cutdown technique is a surgical method used to establish this connection. Doctors usually resort to this technique when less invasive methods have been unsuccessful. These less invasive methods include percutaneous access or Seldinger technique (a way to get into the vein through the skin), using ultrasound to guide the placement of the needle into the vein, and creating a vascular access site in the bone marrow.
Some patients are difficult to treat using the less invasive methods. These include young children with small veins that are hard to feel (palpate), patients with a low volume of blood causing their veins to collapse, and people with vascular disease that alters their vein structure. In these cases, the venous cutdown technique can be a lifesaver.
Anatomy and Physiology of Saphenous Vein Cutdown
The greater saphenous vein (GSV) is the longest vein our bodies have. Usually, it’s the go-to spot for a procedure called venous cutdown, which involves making an incision in a vein. This vein is part of the vein system on the surface of our lower extremity, meaning it starts in our foot and goes up the inner part of our leg and upper thigh where it joins with the femoral vein in an area we call the femoral triangle.
At the foot, the GSV begins where the vein at our first toe (the dorsal vein of the first digit) and the vein along the top of our foot (the dorsal venous arch) join together. It then goes up the inside of our leg close to a nerve called the saphenous nerve, which is very important to keep safe during surgeries that need this vein. Behinds the knee, this vein passes over the back of the part of our thigh bone (the medial condyle of the femur bone).
Then it slightly veers to the side along the front of our upper thigh before it goes through an opening in a layer of tissue we call the fascia lata. This opening is known as the saphenous opening, where it joins the femoral vein to form the saphenofemoral junction. Because of how consistently it’s in the same place and its location at the ankle area just in front of the bony part on the inner side of the ankle (the medial malleolus), this vein is ideal for venous cutdown. This procedure allows swift access and very little need to separate tissues.
Not only this, but the GSV is also the most commonly used vessel for certain heart surgeries, like cardiovascular bypass operations — surgeries that use grafts (transplanted tissue) to bypass blocked parts of arteries to improve blood supply to the heart.
Why do People Need Saphenous Vein Cutdown
A venous cutdown is a medical procedure where a doctor makes a small incision on the skin to access a vein. It’s often performed when a doctor isn’t able to access a vein through the usual method, which is by inserting a needle through the skin and into the vein. This can happen due to various reasons.
A venous cutdown might be needed in different situations, such as:
- For infants, children, and adults who are in shock. This is because the body’s reaction to severe stress, injury, or illness can make it difficult to access veins in the usual way.
- For patients who have burns or scars that make it hard to find a suitable vein.
- When a person’s body structure is different – this could be due to injuries, surgery, or a health condition that changes the usual layout of the veins.
- During a cardiac arrest if the femoral pulse (the pulse in the thigh) can’t be felt. A quick venous cutdown can often provide rapid access to the circulatory system.
- When patients need treatment quickly and normal methods like inserting an IV line or accessing a central vein aren’t possible.
- In individuals who frequently use intravenous (IV) drugs and have clotted veins, making them difficult to access.
- In a type of surgery called ‘vascular lower extremity bypass operations’. This is when a vein from one part of the body is used to bypass a blocked blood vessel in the leg.
- In vascular operations that require a vein patch, which often involves placing a piece of vein over a hole or weak area in a blood vessel.
In these situations, a venous cutdown procedure can be a crucial step to ensure that treatments or drugs can be delivered quickly and efficiently to the patient.
When a Person Should Avoid Saphenous Vein Cutdown
A cutdown, which is a surgical procedure where a doctor cuts into a vein for access, may not be possible if a person has experienced injury at the place where the cutdown is planned to be carried out. In situations where a person has sustained a severe pelvic injury that might have damaged the large veins (the iliac veins) in the pelvis, a cutdown should not be done.
Also, a cutdown may not be done if there is an active infection at the site where the procedure is planned to be performed, if the patient has a disorder that affects their blood clotting ability (coagulopathies), or if it’s possible to gain access to the veins through less invasive methods.
If someone has had an injury to both legs that might have damaged the great saphenous vein (GSV) – a major vein running along the length of the leg – a different vein, known as the basilic vein situated in the upper arm, could potentially be used instead.
Equipment used for Saphenous Vein Cutdown
In order to prepare your skin for the procedure, a solution of Povidone-iodine or chlorhexidine – disinfectants used to prevent infection – will be used.
The medical team will be wearing protective items such as a gown, mask, eye protection, and sterile gloves to ensure the procedure is completed in a safe and bacteria-free environment.
A scalpel, which is a small, sharp knife, will be used during the procedure. Silk ties – thin strings made of silk – are used to secure things in place during the surgery.
Curved hemostats, which you can think of as special pliers, or right-angle instruments will be used to control bleeding by clamping down on blood vessels. Smooth pickups are used to hold and manipulate delicate tissues.
An IV cannula, which is a small tube placed in your vein to deliver fluids and medication to your body, will be used. Along with this, an IV fluid bag and tubing – essentially a water bag and a tube – will deliver essential fluids into your body during the procedure.
Finally, the team will use adhesive tape on your skin as needed. This is just a special kind of medical tape that is safe to use on skin, and it helps protect your wound and keep everything clean after the surgery.
Who is needed to perform Saphenous Vein Cutdown?
A treatment known as a GSV cut down may be carried out by any skilled healthcare provider, like a surgeon or a medical trainee. Ideally, they will have someone helping them by handing them the necessary tools and supplies.
In urgent cases, like severe injuries, a team that includes a trauma surgeon, an emergency room doctor, and a nurse work together to quickly establish intravenous access (a way to give you medicine directly into a vein) and stabilize you.
Preparing for Saphenous Vein Cutdown
Before a surgery or procedure, a patient might receive a local anesthetic, like a 1% or 2% lidocaine solution. This is a sort of numbing medicine that helps to reduce pain during the procedure. This medicine may or may not be mixed with something called epinephrine. The decision to use anesthetic depends on the urgency of the situation and the patient’s unique condition.
The doctor might also feel for a vein called the saphenous vein, located near the inner ankle, or medial malleolus. This vein can be harder to find in patients who have low blood volume, a condition called hypovolemic shock.
Before beginning the procedure, it’s important for the doctor to have all necessary equipment ready and within reach. This helps ensure the procedure goes smoothly and safely.
How is Saphenous Vein Cutdown performed
The cutdown procedure starts with cleaning the area on the inside of your ankle (medial malleolus) and covering it with sterile materials. A bony part of the ankle (medial malleolus) acts as the reference point for this process.
The doctor will then make a small cut about 1 cm to the front and 1 cm above this point, which is the estimated location of the GSV (a vein). The cut is about 3 cm long and made using a sharp instrument known as a scalpel. The doctor will then use a curved instrument (hemostat), to carefully separate the skin and tissue that cover the vein. They are careful during this process because the vein is located close to the skin’s surface.
Once the vein is visible, the doctor will remove tissue around the vein, approximately 2 cm long, to make space for a strong thread (3-0 silk). This thread is attached to both ends of the vein. The doctor needs to pay close attention during this period to avoid hurting a nerve that runs beside the vein. The threads attached to the vein help to make the vein tight and safe, and to gently lift the vein into the operation area. A hemostat can be used to pull on the vein in a safe direction to prepare it for entry.
The doctor then introduces a thin tube or catheter in the vein using either a small cut with a scalpel (large enough for a larger IV tube) or a needle (Seldinger technique). If a scalpel is used, the hemostat is placed behind the vein that is adjusted to help cut about 40% across the vein. This entry to the vein is then secured by pulling the threads that encircle the vein and the end part of the tubing. The threads are secured tight, and the end part of the vein is tied with a silk suture (thread). The tubing is further secured to the skin using tape or thread to prevent it from falling out.
Possible Complications of Saphenous Vein Cutdown
The venous cutdown technique is a medical procedure that may have some risks, such as infection, unsuccessful insertion of a tube into a vein (failed cannulation), heavy bleeding (hemorrhage), injury to a nerve, and air bubbles entering the bloodstream (air embolism). To decrease the chance of these complications, it’s typically advised to remove the inserted tube within 12 to 24 hours.
What Else Should I Know About Saphenous Vein Cutdown?
The medical procedure of making a small cut to access the greater saphenous vein – a large vein in your leg – can be very effective when there’s a need for quick access to a vein and other less invasive methods have not been successful. This process is often carried out near the ankle, away from the head and torso. This makes it a suitable method, particularly during intensive treatments like major resuscitation efforts, and might be very handy during emergency situations following a severe accident.
