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

Background Major vascular surgery in patients with significant cardiovascular comorbidity presents substantial perioperative challenges because of limited cardiovascular reserve, haemodynamic stress, and medication management. The presence of a permanent pacemaker additionally requires assessment of device function, pacing dependence, and potential electromagnetic interference. This case is notable for the integrated use of sole epidural anaesthesia, individualized pacemaker management, and carefully timed perioperative anticoagulation in a patient with multiple cardiovascular comorbidities undergoing femoropopliteal bypass. Case presentation A 63-year-old man with ischaemic heart disease, previous percutaneous transluminal coronary angioplasty 5 years earlier, permanent pacemaker, peripheral vascular disease, hypertension, and type 2 diabetes mellitus was scheduled for elective femoropopliteal bypass. His functional capacity was <4 metabolic equivalents (METs), and he was classified as American Society of Anesthesiologists physical status III. Preoperative echocardiography demonstrated a left ventricular ejection fraction of 46% with regional wall-motion abnormalities. Baseline blood pressure was 150/80 mmHg, heart rate 82 beats/min, and SpO₂ 97%. Haemoglobin was 9.4 g/dL, serum creatinine 0.5 mg/dL, and INR 1.03. Pacemaker position and function were evaluated by an electrophysiologist one day before surgery, with the device programmed to VOO asynchronous mode and approximately 12 years of battery longevity. Enoxaparin was withheld 12 h before surgery. Following multidisciplinary assessment, sole epidural anaesthesia was selected. An L1–L2 epidural catheter was inserted using an 18-gauge Tuohy needle and secured at 11 cm. Following a 6-mL test dose of 0.5% ropivacaine, anaesthesia was maintained with 0.5% ropivacaine at 6 mL/h. Continuous ECG, invasive arterial blood pressure, SpO₂, and urine output monitoring were performed. During the 3.5-hour procedure, haemodynamics remained stable, with no major complications. Estimated blood loss was 350 mL and 750 mL crystalloid was administered. Postoperative epidural analgesia was maintained using 0.2% ropivacaine with fentanyl 2 μg/mL at 5 mL/h. Conclusion This case demonstrates the feasibility of individualized sole epidural anaesthesia for major lower-extremity vascular surgery in a selected patient with significant cardiovascular comorbidity and a permanent pacemaker. The perioperative course included careful cardiovascular and device assessment, coordinated anticoagulation management, invasive haemodynamic monitoring, and continuous epidural anaesthesia without major documented complications. The case emphasizes individualized patient selection and multidisciplinary planning rather than superiority of epidural over general anaesthesia.