JOURNAL

 VENOUS CUT DOWN: A QUICKER AND SAFER TECHNIQUE

 Introduction
 Venous cut down is an emergency procedure that is potentially life saving. It is
taught in the ATLS (Advanced Trauma Life Support) course, and might often need to
be performed by the inexperienced in severely ill trauma patients. It is one of the few
modern surgical procedures in which speed is a crucial factor due to the presence of
hypovolemic shock. An important drawback is the difficulty in cannulation of the
vein. We describe simple modifications in the conventional technique that make the
procedure safer and faster.
 Technique
 Step I
 The great saphenous vein at the ankle is commonly used for the procedure; although other sites
are also available. After isolation of the vein in the usual manner1, a loop of thread is passed under
the vein as shown in the figure 1. The apex of the loop is then divided.
Step 2

 The distal ligature is knotted and the ends of the proximal ligature are held without knotting.
A needle (21G needle or the needle of the intravenous cannula which is to be used for the
cannulation) is used to transfix the vein at the proposed site of cannulation, as shown in
figure 2.
Step 3:

 The circumference of the vein anterior to the needle is almost completely incised with a scalpel as
shown in figure 3. The needle prevents injury to the posterior wall of the vein and also facilitates a
clean-cut incision.
Step 4:

 The intravenous cannula without the inner needle is then introduced into the venotomy opening,
with the needle steadying the vein (Figure 4). The needle is then removed, the proximal ligature
tied over the cannula and the wound closed.
Discussion
Venous cut down is an effective option for venous access in multisystem
trauma and hypovolemic shock, when peripheral cannulation becomes
difficult or impossible. Central venous access has a greater complication rate
and requires more experience and skill than a venous cut down. There is also
the potential for serious complications related to attempted central venous
catheter placement, i.e., pneumo- or haemo-thorax, in a patient who may
already be unstable2. The advantage of measuring central venous pressure by
central venous access is not important in the initial management of most
shocked patients.
The complications of venous cutdown are cellulitis, haematoma, phlebitis,
perforation of the posterior wall of the vein, venous thrombosis and nerve and
arterial transection2. Perforation of the posterior wall of the vein can occur
during venotomy or vigorous attempts at cannulation. By the use of the
described technique, perforation of the posterior wall during venotomy
becomes unlikely. Also, cannulation of the vein becomes easy because of the
presence of a well-defined opening in the anterior wall of the vein.

References:
1.                  McIntosh BB, Dulchavsky SA. Peripheral vascular cutdown. Cr
Care Clin 1992; 8: 807-18.
2.                  Shock. Chapter 3. Advanced trauma life support student course
manual. 6th edition. American
                 College of Surgeons, Chicago. 1997; 87-125.