atherosclerosis has a complex etiology that leads to arterial obstruction and often results in inadequate perfusion of the distal limbs .
patients with atherosclerosis can have severe complications of this condition , with widespread systemic manifestations , and the operations undertaken are often challenging for anesthesiologists .
a 79-year - old woman with chronic heart failure and respiratory dysfunction presented with bilateral gangrene of the distal lower extremities with obstruction of the left common iliac artery due to atherosclerosis .
general anesthesia was induced after performing multiple nerve blocks including quadratus lumborum , sciatic nerve , femoral nerve , lateral femoral cutaneous nerve , and obturator nerve blocks .
the surgery was completed ; the patient remained comfortable and awake without the need for further analgesics .
quadratus lumborum block may be a useful anesthetic technique to perform femoral  femoral bypass .
the quadratus lumborum block ( qlb ) was first reported as anesthesia for abdominal wall surgery .
recently , ultrasound - guided qlb has been reported for postoperative analgesia following abdominal surgery .
however , it was reported that the analgesia region of the qlb is broader than that of the transverse abdominis plane block , and the qlb additionally has some splanchnodynia .
atherosclerosis is a systemic disease which can affect blood vessels , resulting in tissue ischemia , often with devastating clinical consequences .
patients with atherosclerosis commonly have widespread systemic manifestations such as ischemic heart disease , brain infarction , aortic aneurysm , and aortic dissection .
a 79-year - old woman had obstruction of the left common iliac artery due to atherosclerosis and consequently developed gangrenous necrosis affecting both distal lower extremities .
the past medical history included a left thoracoplasty for pulmonary tuberculosis , and refractory congestive heart failure with atrial fibrillation .
echocardiography showed cardiomegaly with mild aortic valve regurgitation , mild mitral valve regurgitation , and moderate tricuspid valve regurgitation .
she was initially planned to undergo extensive debridement of both feet to limit progression of infection .
however , the surgery was canceled because spinal anesthesia failed due to severe scoliosis and the vertebral deformity .
two weeks later , she had a fever of 38.5c , and laboratory data revealed a white blood cell count of 20,700/l and a c - reactive protein level of 5.3  mg / dl , consistent with systemic inflammation .
the surgeons in charge of her care decided to perform emergency amputation of both feet due to more extensive necrosis , and a femoral  femoral bypass graft to allow her to keep as much of her lower extremities as possible to facilitate future rehabilitation .
general anesthesia was considered for the planned procedure ; however , the patient was critically ill .
her respiratory condition worsened and the percutaneous oxygen saturation ( by pulse oximetry ) decreased to 93% while receiving 3  l / min of oxygen by nasal prongs .
these nerve blocks included the qlb for the femoral  femoral bypass and a lumbar plexus block and sciatic nerve block for the bilateral foot amputations .
the patient was in the prone position and the qlb was performed under ultrasound guidance with a 6 to 13-hz high - frequency linear probe and a 22-gauge peripheral nerve block needle .
the probe was placed over the lateral abdomen to identify the abdominal muscles , and then moved dorsally to confirm the location of the quadratus lumborum muscle ( fig .
we inserted the nerve block needle and injected radiocontrast ( 15  ml of 0.08% iotrolan ) ( fig .
the contrast material spread from the iliac crest to the inferior costal margin , which indicated correct position of the tip of the needle .
the injection point for the quadratus lumborum block is on the posterior aspect of the quadratus lumborum muscle .
this triangular image suggests that the quadratus lumborum block was performed by sub - fascial injection of the local anesthetic agent .
the lumbar plexus could not be successfully identified using the nerve stimulator or ultrasound guidance due to the severe deformity of the vertebrae . instead of a lumbar plexus block
, we performed a combination of nerve blocks including a femoral nerve block , a lateral femoral cutaneous nerve block , and an obturator nerve block .
local anesthetic , 0.125% levobupivacaine was used ( 7  ml for the femoral nerve , 3  ml for lateral femoral cutaneous nerve , 8  ml for the obturator nerve , and 10  ml for the sciatic nerve ) for all nerve blocks .
the total amount of local anesthetic used for all peripheral nerve blocks was 86  ml .
general anesthesia was induced using 1% sevoflurane with 6l / min of 50% oxygen administered by facemask , and without muscle relaxants to maintain spontaneous ventilation .
the blood pressure decreased from 100/70 to 80/60  mm hg , and the heart rate increased from 90 to 140  bpm , with intermittent intravenous administration of 4  mg of ephedrine and/or 0.1  mg of phenylephrine , and continuous infusion of 0.01  mg of noradrenaline .
we decided to stop general anesthesia about 10  minutes after starting the procedure because of continuing deterioration in hemodynamics . at that time
, the surgeons were exposing the right femoral artery , and had not yet started the left side . after stopping sevoflurane inhalation ,
the anesthesia used for performing a femoral  femoral bypass graft is usually general anesthesia , spinal anesthesia , or epidural anesthesia .
general anesthesia is the most popular approach for this procedure , but it is also associated with higher morbidity compared to regional anesthesia . in the case of a critically ill patient , femoral
peripheral nerves derived from the lumbar plexus are widely distributed in the inguinal region , the area involved with a femoral  femoral bypass , and explains why local anesthetic infiltration may be insufficient to relieve surgical pain during a femoral  femoral bypass . the qlb is reported to induce analgesia from t10 to l1 .
we expected that a qlb would be useful for performing a femoral  femoral bypass .
one hypothesis is that local anesthetic spreads from the quadratus lumborum muscle to the neighboring paravertebral space , and acts at several nerve roots . the qlb has been reportedly used for postoperative analgesia of various abdominal procedures including cesarean section , laparoscopy , colostomy , and pyeloplasty
this is the first report of using a qlb to perform a femoral  femoral bypass .
 abstractintroduction : atherosclerosis has a complex etiology that leads to arterial obstruction and often results in inadequate perfusion of the distal limbs . 
 patients with atherosclerosis can have severe complications of this condition , with widespread systemic manifestations , and the operations undertaken are often challenging for anesthesiologists.case report : a 79-year - old woman with chronic heart failure and respiratory dysfunction presented with bilateral gangrene of the distal lower extremities with obstruction of the left common iliac artery due to atherosclerosis . 
 femoral  
 femoral bypass graft and bilateral foot amputations were planned . 
 spinal anesthesia failed due to severe scoliosis and deformed vertebrae . 
 general anesthesia was induced after performing multiple nerve blocks including quadratus lumborum , sciatic nerve , femoral nerve , lateral femoral cutaneous nerve , and obturator nerve blocks . 
 however , general anesthesia was abandoned because of deterioration in systemic perfusion . 
 the surgery was completed ; the patient remained comfortable and awake without the need for further analgesics.conclusion:quadratus lumborum block may be a useful anesthetic technique to perform femoral  femoral bypass . 
Introduction:
Case report:
Conclusion:
Introduction
Case report
Discussion