A femoral cutdown is a surgical procedure that creates direct access to the femoral artery or vein, which are large blood vessels located in the groin area. The technique involves making a small incision in the skin to expose the vessel. This method is employed when other, less invasive methods of accessing a patient’s circulatory system are not feasible or have failed.
Medical Indications for a Femoral Cutdown
A femoral cutdown is reserved for specific and often urgent medical situations. It is frequently used in emergencies when a patient is in shock and their blood vessels are collapsed, making standard needle-based access difficult. The procedure is also indicated for patients whose surface landmarks are obscured, such as in cases of severe obesity, extensive injuries, or significant burns.
The technique may also be necessary when a patient’s vessels are affected by disease or scarring from previous procedures or intravenous drug use, which can make the standard percutaneous approach impossible. In some pediatric cases, particularly with infants, a cutdown may be preferred because the blood vessels are too small and fragile for conventional needle insertion. Another reason for performing a femoral cutdown is the need to insert large-bore catheters or specialized medical devices that are too large to be placed through a needle, such as those required for extracorporeal membrane oxygenation (ECMO).
The Surgical Procedure
The procedure begins with administering anesthesia, which may be local or general, depending on the patient’s condition and the urgency of the situation. The surgeon then makes a precise incision in the skin over the femoral triangle, a region in the upper inner thigh. Following the incision, the surgeon dissects through layers of tissue to expose the femoral sheath, which contains the femoral artery, vein, and nerve.
Once the target vessel is identified, it is isolated from the surrounding structures. To control blood flow, the surgeon may place temporary sutures or soft vessel loops around the vessel above and below the intended access site. A small incision, known as an arteriotomy or venotomy, is then made directly into the vessel wall, allowing for the insertion of a catheter or cannula.
After the device is in place, the vessel loops are relaxed, and the catheter is sutured to the skin to prevent dislodgement. When the catheter is no longer needed, it is removed. The incision in the vessel is surgically repaired with fine sutures before the skin is closed.
Potential Complications and Management
A femoral cutdown carries potential risks.
- Bleeding or hemorrhage is a concern, given the size of the femoral vessels.
- Wound infection at the incision site may occur and can be treated with antibiotics.
- Thrombosis, the formation of a blood clot, can obstruct blood flow and may require anticoagulant medications.
- Damage to adjacent structures, most notably the femoral nerve, can lead to numbness or weakness in the leg.
- Late complications can include a pseudoaneurysm (a collection of blood outside the vessel wall) or an arteriovenous fistula (an abnormal connection between an artery and a vein).
Recovery and Aftercare
Following the procedure, the patient is monitored for immediate complications, such as bleeding from the incision site or changes in circulation to the leg. The incision site may be sore for several days, and pain medication is provided to manage discomfort. Once the patient is stable, they are given instructions for care at home.
Proper wound care involves keeping the incision clean and dry to prevent infection. Patients are instructed to watch for signs of complications, which include:
- Increasing redness, swelling, or warmth around the incision
- Any discharge from the wound
- Fever
- The development of numbness or tingling in the leg
Activity restrictions are advised for a period to allow the site to heal properly. These restrictions often include avoiding heavy lifting and strenuous physical activity for several weeks.
Modern Alternatives and Current Use
In modern medical practice, the femoral cutdown is performed less frequently due to less invasive techniques. The most prominent alternative is ultrasound-guided percutaneous access. This method uses ultrasound imaging to visualize the femoral vessel in real-time, allowing a clinician to guide a needle into the vessel with high precision, avoiding a surgical incision.
This approach is standard in many clinical settings because it is associated with a quicker recovery and a lower risk of complications. Despite these technological advancements, the femoral cutdown has not become obsolete. It remains a necessary procedure in specific circumstances where ultrasound-guided access is not possible or has failed, and is still considered a skill for surgeons to possess for managing complex vascular access cases.