Neuraxial anesthesia in complex aortic surgery: A feasible option in high-risk patients

Aortoiliac occlusive disease (AIOD) is a severe form of peripheral arterial disease requiring complex vascular reconstruction, typically performed under general anesthesia (GA). However, GA poses significant risks in patients with advanced cardiac disease. We report the case of a 51-year-old male with bilateral critical limb ischemia and extensive AIOD, complicated by ischemic heart disease, reduced ejection fraction (20%-25%), diabetes, and hypertension. The patient underwent aortic bifemoral bypass, aortic endarterectomy, bilateral femoral endarterectomy, and profundoplasty under thoracic epidural anesthesia (TEA) with intraoperative sedation. TEA provides effective surgical anesthesia, adequate hemodynamic control, and excellent pain relief. Intraoperative hypotension was managed with a norepinephrine infusion. Postoperative analgesia was achieved using epidural ropivacaine-fentanyl infusion and multimodal medications. The patient had a stable course, required only brief ICU monitoring, and was transferred to the ward with well-controlled pain. This case demonstrates the feasibility and safety of TEA as an alternative to GA in high-risk vascular patients. TEA may reduce cardiac stress, improve pain control, and minimize pulmonary complications in select patients undergoing extensive aortic procedures. Further studies are warranted to support wider use of regional techniques in high-risk vascular surgeries.