Femoral Venous Cutdown 
Alexander Mina and Britney L. Grayson 
 
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:  
When central venous access is needed in a 
neonate who is not a candidate for umbilical 
cannulation, a femoral venous cutdown is a 
reasonable option.  
In preparing for surgical venous access in a 
neonate, take extra care to avoid hypothermia. 
Performing the procedure on a overhead heated 
neonatal bed is one way to preserve heat, as is using 
a space heater at a safe distance (>1.5 meters) from 
the infant. Full barrier precautions (cap, mask, sterile 
gloves, sterile gown and full body drape) have been 
shown to reduce the risk of central line associated 
bloodstream infection. As intubation is avoided 
whenever possible, it is helpful to have an assistant 
in the room to aid in immobilizing the legs of the 
patient. Infiltrated local anesthetic is used in addition 
to oral dextrose solution to calm the infant. 
The surgeon will require 2 fine smooth 
forceps, 3 mosquito hemostats, one 4-0 absorbable 
stitch, one 3-0 nonabsorbable stitch, a needle driver, 
suture scissors, an 11-blade scalpel, and the 
intravenous line to be placed. To tunnel the line, a 
frazier tip suction is helpful. For neonates weighing 
600-999 grams, a 1.5 – 2 Fr catheter is suitable. For 
1000 to 1500 kg, a 2 – 2.5 Fr catheter may be used. 
For neonates larger than 1500 g, a 3 Fr catheter is 
best used. 
Femoral venous cutdown proceeds in the 
following steps 
● Securing the infant, preparing and draping 
● Infiltration of local anesthetic 
● Cutdown, identification and isolation of the 
femoral vein 
● Insertion of the cannula, including tunneling 
● Securing the cannula and closing the skin 
 
Steps: 
1. Warm the operating theatre, with a goal 
temperature of 25-28°C. 
2. The patient should be connected to a monitor and 
the anesthetist (or other assistant) prepared with 
dextrose solution to be given per oral on a gloved 
finger. The infant’s arms can be swaddled. 
Alternatively, a very small infant can be secured 
with tape. 
 
This 800g neonate is secured to the bedsheet with tape. 
Dextrose solution on a gloved finger is used to calm the infant. 
The room is warmed and no sedation is given. 
 
3. Aseptic technique is observed with bilateral 
groins and legs of the patient prepared and 
draped, to the knees.  
Take caution using 2% chlorhexidine on infants 
weighing less than 1 kg or who are <32 weeks 
corrected gestational age as it can cause skin 
burns. We recommend the use of 0.5% 
chlorhexidine for these smallest infants. 
4. Palpate the artery to identify the location of the 
medially adjacent vein. Infiltration of 0.25% 
bupivacaine up to 0.5 ml intradermally is 
sufficient and safe for every neonate. 
 
Palpate the femoral artery pulsation. In infants weighing less 
than 1kg, it may be difficult or impossible to feel this pulsation. 
Note that the prepared area allows access to both groins, all 
the way down to the knees to allow the catheter to be tunneled.  
Femoral Venous Cutdown 
Alexander Mina and Britney L. Grayson 
 
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  
 
 
Inject 0.25% bupivacaine up to 0.5mL about 1cm below the 
inguinal ligament 
 
5. Using the 11-blade, carefully make a 1 cm 
incision overlying and perpendicular to the vein, 
approximately 1 finger breadth beneath the 
inguinal ligament. 
 
The incision is carefully made, only through the skin and no 
deeper.  
 
6. Using blunt dissection, spread the subcutaneous 
tissues until the femoral neurovascular bundle is 
identified. Dissect and isolate the vein, being 
careful to avoid the more lateral femoral artery 
and nerve. The vein is the most medial structure 
in the neurovascular bundle. 
 
Gently dissect below the skin and locate the femoral vessels. 
The vein will be the most medial structure, though this anatomy 
may be confusing in the smallest of infants.  
 
 
Once the vascular structures are seen, dissect very carefully 
using a fine mosquito hemostat or fine right-angle clamp until 
the femoral vein is isolated from the artery. 
 
7. Pass a small absorbable tie proximal and distal to 
the planned venotomy site and secure the untied 
ends with mosquito hemostats.  
Femoral Venous Cutdown 
Alexander Mina and Britney L. Grayson 
 
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  
 
 
Pass a fine tie underneath the dissected vein at both the 
proximal and distal ends of the dissection. 
 
8. If tunneling, next make a stab incision on the 
anteromedial thigh, just above the knee. Pass a 
Frazier tip suction from the groin incision down 
through the knee incision and then pass the 
venous line into the suction catheter and pull 
through to the groin, creating a subcutaneous 
tunnel. 
Even if a long tunnel is not possible (due to 
catheter length,) we still recommend tunneling 
the catheter at least 1 cm away from the groin 
incision site. This can easily be done with a 
mosquito hemostat. 
 
 
Dissect bluntly in the space where the catheter will be tunneled.  
 
Pass the fragile catheter in an atraumatic manner by placing a 
fine tip (Frazier) suction in the dissected space, cutting the skin 
over the tip with a scalpel, and passing the catheter through the 
suction.  
 
9. Trim the catheter to the desired length. We 
measure it from the groin incision to 1 cm above 
the umbilicus and then cut at a 45 degree angle to 
facilitate its entry into the vessel.  
 
With the catheter passed fully through the subcutaneous tunnel, 
measure its edge at the level of the umbilicus and cut it at a 45 
degree angle with a scalpel blade. The part that will be removed 
is grasped, to prevent damage.   
 
10. With your assistant elevating the mosquito 
hemostats and your non-dominant hand gently 
holding the anterior wall of the vein, turn the 11-
blade up and make a venotomy in the transverse 
orientation ~50% of the circumference of the 
Femoral Venous Cutdown 
Alexander Mina and Britney L. Grayson 
 
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  
 
vein. Place the scalpel down, pick up a smooth 
forceps and gently feed the catheter into the vein.  
 
Make a transverse venotomy through 50% of the circumference 
of the vein using a scalpel blade. 
 
 
Carefully pass the catheter into the vein.  
 
 
Confirm that the catheter is patent and in the vein by aspirating 
it gently. You may get only a small amount of blood in the hub 
of the catheter.  
 
11. Tie the proximal and distal absorbable sutures 
that were secured by the mosquito hemostats and 
ensure hemostasis is achieved.  
12. Secure the line at the exit point with the prolene 
suture and then close the groin incision in layers- 
one simple interrupted absorbable stitch to 
reapproximate the fat layer over the vein and then 
either running or interrupted absorbable stitches 
in the skin, taking care to not puncture the 
catheter.  
 
The catheter secured in place and the skin incision closed. Some 
catheters will have a channel to accommodate the suture at the 
hub, others (like this one) will not. 
 
13. Place a sterile dressing over the exit site of the 
line. Label with the date and time of dressing 
placement.  
Femoral Venous Cutdown 
Alexander Mina and Britney L. Grayson 
 
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  
 
14. An abdominal x-ray should be obtained prior to 
use to confirm appropriate placement. 
 
Pitfalls 
● Hematoma formation may occur if bleeding is 
not controlled prior to closing the skin.  
● Limb edema may develop as a result of ligating 
the distal femoral vein. A crepe bandage can be 
gently applied to assist in venous drainage. 
Capillary refill of the limb should be closely 
monitored at the foot. Some surgeons remove the 
ties after catheter insertion and do not ligate the 
vein at all. 
● Line thrombosis or occlusion may occur due to 
the small diameter of the lumen. The best way to 
avoid this is to keep continuous fluids running, at 
the lowest rate possible on the pump. If 
absolutely necessary, 50 units/ml heparin can be 
injected only to the level of the blockage. Do not 
attempt to “power flush” rather, allow the heparin 
to dwell before aspirating it out and then flushing 
the line. 
● Transection of the vein during venotomy may 
occur. If cannulation is not possible, tie off both 
ends of the vein.  
● Infection can occur at any time. Infections at the 
insertion site are often treated with antibiotics 
and topical wound care. Central line associated 
bloodstream infections can lead to serious sepsis. 
Any febrile infant with central venous access 
should have blood cultures drawn immediately. 
● Damage to surrounding structures – femoral 
artery and femoral nerve, both of which are 
located laterally to the vein 
 
Alexander Mina 
Vanderbilt University 
Tennessee, USA 
 
Britney L. Grayson, MD, PhD, FAAP, FCS(ECSA) 
AIC Kijabe Hospital 
Kenya 
 
January 2022 
 
