Background and Aims The perioperative anesthetic management of the vast majority of patients undergoing vascular surgery proves to be quite challenging, due to the multiple comorbidities. We present the case of a patient who underwent urgent axillofemoral bypass surgery, under Peripheral Nerve Block (PNB) and Monitored Anaesthesia Care (MAC) with bispectral index (BIS) values guiding the management of sedation.

Methods A 76 years old man, ASA III- IV, with critical lower limb ischemia, presented for urgent axillofemoral bypass surgery. Upon his arrival in the operation room dypnoea, use of accessory muscles and hypoxemia (SpO₂: 81% on room air and pO₂: 45 mmHg), due to a new-onset lower airway infection were noticed. From his past medical history coronary artery disease, diabetes mellitus type II, hypertension, hyperlipidemia, chronic kidney disease requiring dialysis, chronic obstructive pulmonary disease (COPD) and obesity were revealed.

Results Based on the aforementioned reasons, and mainly due to the concomitant lower airway infection, the avoidance of general anaesthesia (GA) was decided. Hence, after obtaining informed consent from the patient, the combination of PNB (ultrasound-guided supraclavicular and fascia iliaca blocks) with BIS-guided MAC (dexmedetomidine) were employed. The patient received supplemental oxygen therapy. The surgery was successfully completed after two hours and the patient was discharged without any awareness or any other complication from the post-anaesthesia care unit (PACU).

Conclusions PNBs combined with MAC and dexmedetomidine seems to be a reliable and safe alternative for axillofemoral bypass surgery when GA should be avoided.