high - risk vascular surgery patients , including those with thrombotic disorders , present safety and technical challenges for anesthetic management . given the poor tolerance of these patients to hemodynamic perturbations , the safest methods should be considered for surgical anesthesia.1 the factor v leiden ( fvl ) mutation , a single point mutation that confers factor v resistance to protein c degradation , is the most common genetic cause of thrombophilia.2 in this case report , we discuss the successful use of infraclavicular brachial plexus , thoracic paravertebral , and unilateral subarachnoid blocks for a patient with fvl mutation and left axillary artery occlusion .
a 58-year - old , 76 kg , 162 cm tall , american society of anesthesiologists ( asa ) physical status ii woman was scheduled for axillo - brachial bypass to treat left axillary artery occlusion ( subclavian steal syndrome ) .
the surgeon planned to harvest the patient s left distal saphenous vein for axillo - brachial bypass .
the patient had a history of hypertension , chronic obstructive pulmonary disease ( copd ) ( fev1/fvc [ forced expiratory volume in 1 second / forced vital capacity ] ratio : 50% by spirometry ) and fvl mutation .
her medications included valsartan 160 mg plus hydrochlorothiazide 25 mg daily , aspirin 300 mg daily , formoterol 12 g plus budesonide 400 g inhaled twice daily , tiotropium bromide 18 g inhaled daily , and theophylline 200 mg twice daily .
pre - operative platelet count , bleeding time , prothrombin time , activated partial thromboplastin time ( aptt ) , and international normalized ratio ( inr ) were normal .
low molecular weight heparin ( lmwh ) 40 mg was administered subcutaneously 12 hours before the procedure , and her daily copd medications ( formoterol / budesonide inhaler , tiotropium inhaler , and theophylline ) were given on the morning of the procedure .
after applying electrocardiography , noninvasive arterial blood pressure , and pulse oximetry monitors , the patient was placed in the sitting position and oxygen was applied via face mask at a rate of 2 l per minute .
she was given midazolam 1 mg and fentanyl 25 g for sedation , and 500 ml of crystalloid solution intravenously .
the thoracic paravertebral block ( tpvb ) was performed according to the method of eason and wyatt.3 palpation was used to localize the seventh cervical vertebra ( c7 ) and first thoracic vertebra ( t1 ) at the tip of the scapula .
spinous processes of t1 through t5 were outlined , and a point was marked 2.5 cm left lateral to each of the spinous processes ( figure 1 ) .
skin and subcutaneous tissue were anesthetized along the vertical line with 4 ml lidocaine 1% .
a 22-gauge spinal needle was inserted 2.5 cm lateral to the spinous process of t1 , in the direction of t1 .
the transverse process was found with the tip of the needle , and then the needle was withdrawn to the skin and redirected caudally to slide under the transverse process .
the needle was advanced to the paravertebral space , as identified by loss of resistance to air .
after the paravertebral space was identified and aspiration did not produce blood , air , or cerebrospinal fluid , 5 ml of levobupivacaine was injected , and the needle was removed .
the patient was placed supine and observed for signs of intravascular or epidural injection and respiratory difficulty .
sensation was assessed by using ice - cold and pin - prick tests , repeated at 5-minute intervals .
we used comlekci et al s technique for infraclavicular block , in which the highest point of the shoulder is taken as a reference point.4 the infraclavicular region was prepared with povidone - iodine . using a 22-gauge , 100 mm insulated needle and a nerve stimulator ( stimuplexb , braun ag , melsungen , germany ) , we assessed hand responses for n. medianus and n. musculocutaneous at 0.4 ma .
a total of 200 mg lidocaine 2% ( 10 ml ) and 150 mg levobupivacain 0.5% ( 30 ml ) was injected slowly with aspirations after every 5 ml ( figure 2 ) . repeated sensory blockade assessments were performed at frequent intervals .
ten minutes after completing the tpvb , unilateral spinal block was performed in the leftdown lateral decubitis position .
a 25-gauge quincke needle was used to introduce 5 mg of hyperbaric bupivacaine 0.5% for induction at the l3l4 interspace .
the left distal saphenous vein was prepared in 15 minutes and the area closed primarily .
the patient recovered from brachial and thoracic paravertebral block in 4 hours and spinal block in 2 hours .
the pain - free period after the procedure was 7 hours at the axillary artery site and 4 hours at the saphenous vein harvest site .
oral medications were started on the second postoperative day , and the patient was discharged on postoperative day 7 without complications .
inherited resistance to activated protein c through fvl mutation leads to a thrombophilic state.5 fvl mutation is the most common inherited risk factor for venous thromboembolism , with heterozygous carriers having a 410-fold increased risk of deep vein thrombosis ( dvt ) and homozygous patients having up to a 100-fold increase in dvt risk.6 while planning the patient s anesthesia management , we searched for methods associated with quick recovery , less postoperative pain , less postoperative nausea and vomiting , reduced postoperative analgesic requirements , reduced association with thromboembolic events , and shorter hospital stays . because of the patient s advanced obstructive lung disease , we chose regional anesthesia .
this approach was also chosen in this patient with an fvl mutation because regional anesthesia is associated with a lower risk of thrombosis compared to general anesthesia.7 although we chose an infraclavicular block for arm anesthesia , we performed sensorial blockade of the axillary region using a tpvb at the t1 , t2 , and t3 levels.8 tpvb can be performed with the patient sitting , lying on the side , or prone .
we chose the sitting position because it provides easy identification of landmarks.9 we believed that unilateral low - dose spinal anesthesia would be sufficient for saphenous vein harvest .
hyperbaric bupivacaine at 4 mg and 6 mg doses have been compared and found to be equivalent for unilateral , segmental spinal anesthesia for outpatient knee arthroscopy .
the 4 mg dose appears superior to the 6 mg dose because it produces faster spinal anesthesia induction and the patient achieves discharge criteria significantly earlier.10 we used 5 mg of hyperbaric bupivacaine , which proved adequate during saphenous vein harvest . for most patients , lmwh thromboprophylaxis should be discontinued 1012 hours prior to surgery and coagulation status ( aptt ) should be assessed prior to neuraxial blockade.11 although our patient was prone to thrombosis because of her fvl mutation , we discontinued lmwh , as per general recommendations , 12 hours prior to the procedure . performing a combination of regional techniques on one patient is time consuming , may create intraoperative patient discomfort , and may be associated with higher failure rates .
these factors may also contribute to an increased risk of technique - specific complications and local anesthetic toxicity.12 however , these regional techniques may be suitable alternatives for patients with thrombophilias , because they may be performed with minimal postoperative pain and early recovery without thromboembolic complications .
 anesthetic management of patients with coagulation disorders presents safety and technical challenges . 
 this case describes a 58-year - old woman with factor v leiden mutation who required distal saphenous vein harvest and axillo - brachial bypass to treat axillary artery occlusion . 
 the patient underwent surgery with satisfactory anesthesia using infraclavicular brachial plexus block , thoracic paravertebral block , and unilateral subarachnoid block . 
 these three regional anesthetic interventions were performed in lieu of general anesthesia to minimize risks of thrombotic events , pain , and to decrease recovery time . despite higher failure rates of regional anesthesia , longer time required for procedures , and added discomforts during surgery 
 , the benefits may outweigh risks for selected high - risk patients , including those with factor v leiden mutations . 