Epidural-Only Anesthesia Keeps High-Risk Vascular Patient Stable Through Bypass Surgery

A 63-year-old man with blocked leg arteries, a weakened heart, and a permanent pacemaker has undergone a major femoropopliteal bypass operation without general anesthesia, breathing spontaneously throughout the three-and-a-half-hour procedure while an epidural infusion alone kept him pain-free and hemodynamically stable. The case, reported by anesthesiologists at Yenepoya Medical College Hospital in Mangalore, India, in Frontiers in Anesthesiology, illustrates how careful cardiovascular assessment, pacemaker reprogramming, and precisely timed anticoagulation can be integrated into a single, individualized anesthetic plan for one of the most challenging patient profiles in vascular surgery.

The patient carried a dense cluster of cardiovascular risk factors. He had established ischemic heart disease, having undergone percutaneous transluminal coronary angioplasty roughly five years earlier, along with peripheral vascular disease, hypertension, type 2 diabetes mellitus, and an implanted pacemaker. His functional capacity was limited to fewer than four metabolic equivalents, a threshold widely used to flag elevated perioperative risk, and preoperative echocardiography showed a left ventricular ejection fraction of 46 percent with regional wall-motion abnormalities. He was classified as American Society of Anesthesiologists physical status III. At admission his blood pressure was 150/80 mmHg, heart rate 82 beats per minute, and oxygen saturation 97 percent. Laboratory values included a hemoglobin of 9.4 g/dL, serum creatinine of 0.5 mg/dL, and an INR of 1.03.

Femoropopliteal bypass is a well-established revascularization technique for peripheral arterial disease, but it demands long surgical exposure, shifts in vascular resistance and perfusion, meaningful blood loss, and considerable postoperative pain. In patients whose systemic atherosclerotic burden extends to the coronary arteries, these physiological disturbances can precipitate myocardial ischemia, arrhythmias, or heart failure. The anesthetic technique therefore has to provide good surgical conditions while preserving cardiovascular and respiratory stability, a balance that is difficult to strike when cardiac reserve is already compromised.

Regional and neuraxial techniques have long been used in lower-extremity vascular surgery because they avoid airway instrumentation, minimize systemic anesthetic agents, deliver perioperative analgesia, and produce a controlled, titratable sympathetic block. The evidence base, however, does not show a clear mortality advantage. A recent systematic review and meta-analysis of lower-limb revascularization found no statistically significant reduction in death rates with either neuraxial or regional anesthesia, although neuraxial techniques were associated with fewer pulmonary complications, with low certainty regarding observational evidence of reduced morbidity and cardiac complications. Earlier randomized trials similarly showed broadly comparable cardiac outcomes between carefully conducted epidural and general anesthesia, with one trial finding fewer reoperations for inadequate tissue perfusion in the epidural group and another, the PIRAT trial, recording larger hemodynamic deviations under general anesthesia without differences in myocardial ischemia or major cardiac morbidity.

The pacemaker added a further layer of complexity. Electrosurgical units can generate electromagnetic interference capable of disrupting cardiovascular implantable electronic devices, so the device had to be identified, pacing dependence assessed, and programmed mode and battery status reviewed before a procedure-specific plan could be drawn up. One day before surgery, an electrophysiologist confirmed the pacemaker’s position by chest radiography and interrogated the device to assess pacing parameters, battery status, programmed mode, and underlying rhythm. The device was functioning normally, and the patient was judged to be pacemaker-dependent. Although the baseline programmed mode was DDD, the device was reprogrammed to VOO asynchronous mode before surgery. Because the operation was planned below the umbilicus, the risk of clinically significant electromagnetic interference with a transvenous pacemaker was relatively low, but the team judged that the consequences of inappropriate pacing inhibition in a pacing-dependent patient justified the precaution, given the anticipated use of electrosurgery. The device carried approximately 12 years of battery longevity, and no malfunction was identified.

Anticoagulation posed the second major coordination problem. Low-molecular-weight heparins and other antithrombotic drugs are routine in peripheral vascular disease, yet they complicate neuraxial techniques because neuraxial bleeding, while rare, can cause devastating neurological injury. Enoxaparin was withheld 12 hours before surgery, and the preoperative INR of 1.03 and normal renal function were noted, though the authors caution that such parameters alone are insufficient to define neuraxial safety during LMWH therapy. Postoperatively, enoxaparin 60 mg subcutaneously once daily was started 24 hours after surgery. The epidural catheter was maintained until postoperative day 3, removed 12 hours after the preceding enoxaparin dose, and therapeutic enoxaparin 60 mg was restarted 12 hours after catheter removal, then continued at 12-hour intervals. This sequencing was designed to minimize the risk of neuraxial hematoma while ensuring the patient’s postoperative anticoagulation needs were met.

On the day of surgery, the anesthetic team inserted an L1–L2 epidural catheter using an 18-gauge Tuohy needle with the loss-of-resistance technique and secured it at 11 cm at the skin. After a 6-mL test dose of 0.5% ropivacaine, anesthesia was maintained with a continuous infusion of 0.5% ropivacaine at 6 mL/h. Pinprick testing showed a sensory block extending from L1 to S4 approximately 10 minutes after the initial dose, providing adequate surgical anesthesia without supplemental general anesthesia. The patient remained spontaneously breathing, cooperative, and free of intravenous sedation throughout. Monitoring included continuous ECG, invasive arterial blood pressure, pulse oximetry, and urine output, with the continuous ECG considered particularly important given his pacemaker dependence.

The operation lasted about 3.5 hours. Bipolar electrocautery was used, and no clinically significant electromagnetic interference, inappropriate pacing, or hemodynamic instability attributable to electrocautery was observed. Estimated blood loss was 350 mL, and 750 mL of crystalloid was administered. SpO2 remained between 98.2 and 100 percent, mean arterial pressure stayed above 60 mmHg, and no vasopressor infusion was required. There was no clinically significant tachycardia and no new ECG changes. Postoperative analgesia continued through the epidural catheter with ropivacaine 0.2% plus fentanyl 2 μg/mL at 5 mL/h, and the patient reported satisfactory pain control with no clinically significant motor blockade, respiratory complication, or bladder-related problem.

Recovery proceeded smoothly. Postoperative Doppler assessment demonstrated satisfactory distal arterial flow through the bypass, the operated limb remained warm and pain free, and the limb was salvaged. The patient was mobilized on postoperative day 6 and discharged on postoperative day 10 on oral anticoagulation. He reported good pain control and no significant postoperative discomfort during his hospital stay.

The authors are explicit that this single case does not establish epidural anesthesia as superior to general anesthesia, and they frame the educational value in integration rather than comparison. The 2024 AHA/ACC perioperative guideline calls for individualized management of cardiovascular implantable electronic devices and structured cardiac evaluation when electromagnetic interference is expected, and the American Society of Regional Anesthesia and Pain Medicine’s fifth-edition guidelines offer updated recommendations for patients on antithrombotic therapy undergoing neuraxial procedures. The Third National Audit Project likewise emphasizes patient selection and early identification of neurological complications after neuraxial blockade. What the case demonstrates is feasibility in a selected patient: that incremental, titratable neuraxial blockade, careful device management, coordinated anticoagulation timing, invasive hemodynamic monitoring, and postoperative epidural analgesia can be woven into one coherent plan for a high-risk vascular surgical patient. The main limitation, the authors note, is that a single-patient report cannot establish safety, superiority, or generalizability of the technique compared with alternatives, and much of the claimed benefit of regional anesthesia in peripheral vascular surgery rests on observational evidence subject to confounding. The case instead underscores individualized patient selection and multidisciplinary planning as the decisive factors when managing complex vascular surgical patients.

Subject of Research: A case report of sole epidural anesthesia with pacemaker reprogramming and timed anticoagulation for femoropopliteal bypass in a high-risk patient.

Article Title: Sole epidural anaesthesia for femoropopliteal bypass in a high-risk patient with ischaemic heart disease and a permanent pacemaker: a case report

Article References: Mathew, J. S., Muruganantham, P., Rao, M. S., & Madar, I. H. (2026). Sole epidural anaesthesia for femoropopliteal bypass in a high-risk patient with ischaemic heart disease and a permanent pacemaker: a case report. Frontiers in Anesthesiology, 5, 1975819. https://doi.org/10.3389/fanes.2026.1975819

Image Credits: AI Generated

DOI: 10.3389/fanes.2026.1975819

Keywords: epidural anesthesia, femoropopliteal bypass, peripheral vascular disease, permanent pacemaker, ischemic heart disease, anticoagulation, ropivacaine, vascular surgery, pacemaker dependence, electromagnetic interference, case report, Sole