A femoral cutdown is a minor surgical procedure that involves making a small incision, typically in the groin region, to directly access a blood vessel. This technique allows a physician to see and work with the femoral artery or vein, which are the large vessels that pass through the upper thigh. It serves as a necessary alternative to standard percutaneous access, which is the less-invasive method of inserting a needle and guide wire through the skin to cannulate a vessel. The cutdown provides a reliable, open path to a vessel when a needle-based approach is either impossible or has failed.
Why Surgical Access is Required
Physicians choose a surgical cutdown when percutaneous access is technically challenging or unsuccessful. Conditions that make it difficult to locate or puncture the vessel include significant obesity, scar tissue from previous procedures, or anatomical variations. These factors can obscure the vessel’s location, making standard or ultrasound-guided methods ineffective.
The procedure is also required in emergency situations, such as severe hypovolemic shock where collapsed vessels are difficult to cannulate blindly. Direct surgical visualization ensures rapid access for fluid resuscitation or blood pressure monitoring in time-sensitive trauma cases. A cutdown is also necessary when a very large-caliber sheath or catheter is needed, such as for extracorporeal membrane oxygenation (ECMO) or complex endovascular repairs. The open approach allows for precise placement and secure closure around the larger device, which is difficult to manage percutaneously.
The Procedural Steps of a Femoral Cutdown
The procedure begins with meticulous preparation, including a wide sterile clean and drape of the groin and upper thigh. Local anesthetic is injected to numb the area, though sedation or general anesthesia may be used depending on the patient’s condition. The surgeon then makes an incision, typically a transverse cut in the groin crease or a vertical incision over the femoral vessels.
Once the incision is made, the surgeon uses blunt dissection to carefully move aside fat and connective tissue until the femoral neurovascular bundle is located. This bundle contains the femoral nerve, artery, and vein. Fine surgical instruments are used to gently separate the target vessel from surrounding tissues and the adjacent nerve, providing necessary control for access.
To gain access, the surgeon may place fine sutures around the vessel above and below the intended access point to control blood flow. A small incision (venotomy or arteriotomy) is then made directly into the vessel wall. The catheter or sheath is inserted under direct vision, ensuring correct positioning and preventing damage to the vessel circumference during cannulation.
After the medical device is secured, the vessel incision is closed, often using fine absorbable sutures to repair the opening. If the vessel is permanently ligated, the sutures are tied to close it completely. Finally, the surgeon closes the overlying layers of tissue and the skin incision using stitches, staples, or surgical glue.
Post-Procedure Care and Recovery
Following the cutdown, the patient is monitored in a recovery area for bleeding or swelling at the access site. Nurses frequently check the pulse and color in the leg and foot to ensure proper blood flow is maintained. Pain management is provided as the local anesthetic wears off, as soreness at the incision site is common in the first few days.
Patients are advised to limit hip and leg movement to allow the internal vessel repair and external incision to heal. Keeping the leg straight for a prescribed period prevents tension on the vessel suture line. While hospital stays vary based on complexity, patients are encouraged to begin light walking as soon as safely possible to aid circulation.
Discharge instructions emphasize monitoring the wound site for complications, such as increased redness, warmth, excessive drainage, or fever, which indicate infection. External stitches or staples are usually removed seven to fourteen days after the procedure. Patients are restricted from lifting anything heavier than ten pounds and advised against strenuous activities for several weeks to allow for complete healing.