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Background and Aims Traditionally, thoracic epidural analgesia (TEA) has been considered the gold standard for managing postoperative pain following laparotomy. However, technical challenges and the chronic use of anticoagulants have led anesthesiologists to seek alternative approaches. Ultrasound-guided Erector Spinae Plane Block (ESPB) has emerged as an interfascial plane block offering extensive somatic and visceral abdominal analgesia, demonstrating comparable efficacy to TEA at rest.

Methods Two 54-year-old men, graded ASA-PS III, underwent elective Aorto-Bifemoral Bypass (ABFB). Case one had a history of grade III ischemic cardiomyopathy, while case two presented with moderate obstructive ventilatory defect. Both patients had severe peripheral artery disease. Bilateral ultrasound-guided ESPB was performed using 0.375% ropivacaine, with a total volume of 30 mL for case one and 60 mL for case two, tailored to their anthropometric features. Total intravenous anesthesia was induced, supplemented with intravenous acetaminophen (1g), ketorolac (30mg), and tramadol (100mg). Pain scores were assessed using numerical rating scales (NRS) at rest and during movement. A fixed intravenous analgesia protocol was established, comprising acetaminophen (1g) every 8 hours, metamizol (2g) every 12 hours, and tramadol (100mg) every 8 hours.

Results During the first five postoperative days, no pain scores greater than 3, need for rescue analgesia, or side effects were reported.

Conclusions ESPB, as part of multimodal analgesia, provided optimal pain relief. Studies have highlighted its ability to provide extensive abdominal analgesia, making it a promising alternative to TEA for ABFB. Classified as a superficial block, ESPB presents lower risk to anticoagulated patients than TEA. Further investigation is required for validation.