To the Editor, Vascular surgery patients are commonly afflicted by a multitude of comorbidities, including pulmonary hypertension, that render them a fragile population. Their five-year mortality rate after surgical intervention ranges up to 28%. 1 Pulmonary hypertension has become a familiar challenge for anesthesiologists. Studies investigating the outcome of these patients undergoing non-cardiac surgery have demonstrated a morbidity rate ranging from 14% to 42% and a mortality rate of 0.9% to 7.0%. 2 Recommendations have been made that, when possible, epidural anesthesia be used instead of general anesthesia. 3 Axillary-femoral bypass may be chosen for lower limb revascularization over the preferred aorto-femoral bypass in high-risk patients.We present the case of a 77-yr-old patient with severe pulmonary hypertension (right ventricular systolic pressure 88 mmHg) who underwent axillary-femoral bypass solely with regional anesthesia that was administered via two intrathecal catheters. The patient described gave written consent for this report.The original plan was to use a thoracic epidural catheter and a lumbar intrathecal catheter. The plan was modified, however, after an inadvertent dural puncture in the thoracic area resulting in placement of a thoracic intrathecal catheter. A fentanyl infusion was started and titrated up to 7.5 lgÁhr -1 through the thoracic catheter followed by a 1-mL bolus of 0.5% bupivacaine via the lumbar catheter (which was placed intrathecally, as planned). Subsequently, an infusion of 0.25% bupivacaine was started at 2 mLÁhr -1 . The patient was under sedation with a dexmedetomidine infusion throughout. No loading dose was used. The dexmedetomidine was initially started at 0.2 lgÁkg -1 Áhr -1 and then titrated up to 0.4 lgÁkg -1
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