Critically ill patients who are not candidates for percutaneously placed arterial and venous lines require surgical cutdown. Although significant complications may arise from inadvertent injury to the vessel or associated structures during arterial and venous cutdown, these complications can be minimized by meticulous technique. With attention to site selection and catheter care, the useful life of these complex catheters approaches that of percutaneously placed devices. Finally, although the sequelae of placement by these techniques--including wound and catheter infection, distal ischemia, and vessel ligation--are increased, the need for appropriate intravascular access in these patients far outweighs the potential risks.