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Background and Aims Breast cancer is the most common type of cancer in women. The increase in average life expectancy leads to more comorbid and older women undergoing breast surgery. Usually, modified radical mastectomy is performed under general anesthesia. It is possible and reasonable to choose a less invasive approach in these patients such as peripheral nerve block techniques.

Results We present an 85 year-old woman, ASA IV, diagnosed with advanced invasive carcinoma of the right breast who underwent right radical mastectomy with lymph node dissection. The patient had several comorbidities such as pulmonary hypertension, respiratory failure under night BiPAP and long-term oxygen therapy, heart failure, ischemic cardiomyopathy, chronic kidney disease. Anticipating the high anesthetic risk the anesthesiology team decided to perform the procedure under regional anesthesia. The regional anesthesia performed was based on a belt and brace approach, blocking all the contribution to the right breast. Thus, it was planned a paravertebral block in 3 levels complemented with interectoral, pectoserratus, supraclavicular nerves and a pectointerfascial block. To maintain redundancy and safety a high thoracic epidural catheter was left in place. Due to technical difficulties performing a paravertebral approach in one of the levels a erector spinae plane block was performed as a rescue in T3-T4. All the blocks combined enabled a safe and painless surgery with a minimal sedation for patient’s comfort.

Conclusions It is mandatory to suit the anesthetic technique to the patient. This case illustrates the possibility of performing a major surgery avoiding general anesthesia for the patient‘s best outcome and safety.