Cutdown for Venous Access 
Monica Bianca Balictar and Ariel Santos 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Introduction:  
Secure venous access is crucial in the 
management of any adult or pediatric patient, as a 
means for administering fluids and medications, 
parenteral nutrition, and physiologic, hematologic 
and biochemical monitoring. While percutaneous 
insertions under sonographic guidance are preferred 
as the simplest and least invasive method of access, 
there are some situations in which an open approach 
using venous cutdowns may be the only feasible 
option for vascular access. These include scenarios 
in which patients are being managed in under-
resourced 
areas, 
where 
peripherally-inserted 
catheters 
or 
ultrasound 
machines 
may 
be 
unavailable; 
or 
when 
multiple 
attempts 
at 
percutaneous or intraosseous insertion have failed.  
Umbilical access is preferred for the 
newborn, if possible. Venous cutdowns can be 
performed on the following sites, for long-term 
access: 
 
For adults and older children: 
● Cephalic or Basilic vein 
● Femoral vein 
● Saphenous vein 
 
For infants and younger children: 
● Internal jugular vein 
● External jugular vein 
● Femoral vein 
 
The following materials will be needed for 
the procedure: 
● Personal protective equipment; gown, mask and 
eye protection 
● Chlorhexidine solution 
● Syringe with Lidocaine HCl 1%  
● 10cc syringe with sterile saline 
● Surgical scalpel blade 15 
● Silk/Vicryl 4-0 strands 
● Silk/Vicryl 4-0 atraumatic suture 
● Central line catheter or 5 French sterile feeding 
tube 
● Sterile gauze 
● Sterile drapes  
● Transparent adhesive dressing (antimicrobial 
dressing if available).  
● Sterile needle holder, curved fine-tipped forceps 
(like Mosquito), sharp Iris or Mayo scissors, and 
Senn retractors 
 
Materials and equipment for venous cutdown. 
 
A brief overview of the essential steps for internal 
jugular vein cutdown is listed below: 
● Make a short incision and dissect through the 
muscle. 
● Identify and isolate the internal jugular vein. 
● Apply circumferential proximal and distal 
sutures and ligate the distal (cranial) aspect of the 
vein. 
● Perform venotomy and insert the cannula. 
● Anchor the cannula with a proximal suture 
● Close the wound, anchor the distal aspect of the 
cannula, and apply a sterile dressing. 
 
Steps: 
1. It is crucial to obtain a history of previous central 
line insertion, to aid in the choice of site for 
catheter placement. Clotting studies may be 
considered in the context of a history or 
symptoms and signs of any bleeding disorders.  
2. Venous cutdowns, regardless of site, are 
preferably done under moderate sedation with 
local anesthesia. For very small or premature 
infants, sedation is not needed and the child can 
be calmed by being allowed to suck on a gloved 
finger dipped in dextrose. 
3. Place the patient in supine position, with the head 
turned about 30 degrees to the contralateral side. 
A soft linen pad placed underneath the upper 
torso, specifically under the scapula, allows for 
better exposure by hyperextending and elevating 
the neck. 
Cutdown for Venous Access 
Monica Bianca Balictar and Ariel Santos 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
Patient positioned supine, with the head turned to the 
contralateral side. 
 
4. Thoroughly prepare the skin with chlorhexidine 
antiseptic, from the ipsilateral jawline down to 
the upper chest. Apply and secure sterile drapes 
in place, ensuring adequate space in the field for 
the catheter exit site. The surgeon stands with 
shoulders relaxed, on the side to be cannulated. 
5. Infiltrate local anesthesia into and around the 
planned incision site. Apply a short transverse 
incision along a skin crease, 1-2cm above the 
clavicle, and 1-2cm lateral to the anterior border 
of the sternocleidomastoid muscle, where the 
clavicular and sternal heads diverge. Carry this 
incision down to the subcutaneous tissue, 
applying gentle pressure for hemostasis.  
 
Infiltration of local anesthesia into the planned incision site. 
 
6. Using careful blunt dissection with fine-tipped 
(mosquito) clamps, deepen the incision through 
the platysma fibers, then through the 
sternocleidomastoid muscle, until the carotid 
sheath is reached.  
7. Insert a small (Senn or Ragnell) retractor to help 
expose the vascular bundle, consisting of the 
internal jugular vein laterally and the common 
carotid artery medially. The ipsilateral vagus 
nerve may be visualized in between the two 
vessels.  
Cutdown for Venous Access 
Monica Bianca Balictar and Ariel Santos 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Identification the internal jugular vein, located adjacent to the 
carotid artery. 
 
8. Isolate the internal jugular vein by gently and 
bluntly dissecting along either side of the vessel, 
until a clear plane is developed and it is visibly 
separated from the underlying vascular bundle. 
9. Insert a fine-tipped mosquito clamp underneath 
the vessel to deliver it into the field. Using the 
clamp, insert two 4-0 Silk or Vicryl ties to serve 
as gentle retractors for the proximal and distal 
ends of the vessel.  
 
Isolation of the internal jugular vein from adjacent structures. 
 
 
Application of proximal and distal sutures onto the isolated 
internal jugular vein. 
 
10. Ligate the more cranial, distal suture to prevent 
further inflow of blood into the vessel. 
Alternately, to spare the internal jugular vein, a 
purse-string suture may also be applied along the 
Cutdown for Venous Access 
Monica Bianca Balictar and Ariel Santos 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
circumference of the vessel using a non-cutting 
5-0 Prolene suture to anchor the tube instead of 
ligation. 
11. With a mosquito clamp replaced underneath the 
vessel, apply a short, clean incision on one side 
of the vein, enough to accommodate the prepared 
catheter or feeding tube. 
12. Using non-toothed fine (Adson) forceps, gently 
lift the upper lip of the cut vessel to better expose 
the vessel lumen. Insert 3-4cm of the catheter 
into the lumen, or until adequate backflow of 
blood is encountered to confirm placement. 
There should also be no resistance or bulging 
around the insertion site on pushing sterile saline 
or IV fluids into the catheter. 
 
Catheter inserted into the internal jugular vein. 
 
13. Anchor the tube using the proximally-placed 
suture. Future leaks or loosening of the tube may 
be prevented by first creating a secure knot, then 
passing one end of the suture again underneath 
the vessel, and reinforcing the tube tie with a 
second knot. 
14. Close the wound using an interrupted subdermal 
approach, with 4-0 Vicryl sutures. An additional 
interrupted anchoring suture around the tube may 
be placed to further secure it in place. 
 
Catheter anchored in place and wound closed. Backflow of 
blood on gentle aspiration confirms proper placement within 
the vessel lumen.  
 
15. Apply a sterile transparent adhesive dressing 
over the insertion site. To further prevent 
accidental removal of the tube, secure the more 
distal parts of the tube with thin strips of adhesive 
onto the pre- and postauricular skin. 
 
Cutdown for Venous Access 
Monica Bianca Balictar and Ariel Santos 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Catheter secured with sterile adhesive dressing and reinforced 
distally with adhesive strips. 
 
16. If the catheter is inserted for use as a central line, 
order a subsequent chest radiograph to confirm 
placement of the tube tip just above the right 
atrium. 
 
Variations 
The external jugular vein may be used as an 
alternative branch for vessel cannulation. It is often 
grossly palpable prior to cutting, located superficial 
to and obliquely crossing the sternocleidomastoid. 
While its superficial location allows for more 
minimal dissection, it is often smaller in caliber. 
The same principles apply for great 
saphenous vein cutdown, by preparing and draping 
the anteromedial ankle and making a 1.5 to 2 cm 
transverse incision 1 cm anterior and 1 cm superior 
to the medial malleolus. Avoid this site in pelvic 
injury and lower extremity fractures.  
 
For a great saphenous vein cutdown, make a transverse 
incision between the extensor hallucis longus tendon and the 
medial malleolus. In the unconscious patient, grasp the great 
toe and retract it cranially to demonstrate the tendon. Apply the 
principles in this chapter to isolate, encircle, ligate and 
cannulate the vein.  
 
 
After identification and dissection of the great saphenous vein, 
insertion of the catheter proceeds as described above. Source: 
Charley Randazzo et al, Venous Cutdown. WikEM, The Global 
Emergency Medicine Wiki. July 16, 2021. Available at: 
https://wikem.org/wiki/Venous_cutdown. 
Accessed 
19 
February, 2023 
 
Pitfalls 
● Persistent bleeding may result from inadvertent 
injury of the external jugular vein, internal 
jugular vein, or carotid artery. Take great care 
with handling and isolating vessels, employing 
surgical magnification as needed, and use blunt, 
non-toothed forceps to reduce this risk. It is also 
important to examine the field prior to closure to 
check for any uncontrolled bleeding and 
maintain adequate hemostasis at all times. 
● As with any open procedure, any breaks in 
sterility may result in infection of the wound or a 
catheter-related bloodstream infection. As much 
as possible, conduct the procedure fully gowned 
in a sterile environment, and always use proper 
sterile technique. 
● Catheter malfunction may result from blood clots 
within the lumen, occlusion of the catheter tip via 
a kink or malposition against the vessel wall or 
small branch, and/or stenosis of the vein.  
● Other technical complications to watch out for 
include: 
pneumothorax/hemothorax, 
vessel 
injuries resulting in bleeding and hematomas, 
and air embolism. These may all be avoided with 
proper site choice, careful identification of the 
anatomic structures, and gentle handling of 
vessels and surrounding muscle and soft tissue. 
● Plain Lidocaine can be infiltrated with maximum 
dose of 3 to 4.5 mg/kg. 
Cutdown for Venous Access 
Monica Bianca Balictar and Ariel Santos 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
● Remove the central line once indication for 
placement is no longer present.  
 
Monica Bianca Balictar MD MBA 
Jose Reyes Memorial Medical Center 
Manila, Philippines  
 
Ariel Santos MD FACS FRCSC FCCM 
Texas Tech University of Health Sciences 
Lubbock, Texas, USA 
 
February 2023 
