Intraoperative Placement of Pectoral Nerve Block Catheters: Description of a Novel Technique and Review of the Literature.

Regional and neuraxial anesthesia for pain management after breast surgery is not widely used despite data showing improved postoperative pain control and patient satisfaction scores. We report a case of a 61-year-old woman who underwent bilateral mastectomies, and received postoperative analgesia via pectoral nerves 1 and 2 nerve blocks. This case highlights a previously undescribed technique of prolonged postoperative pain control by intraoperative placement of pectoral nerves 1 and 2 regional anesthesia catheters under direct visualization. Intraoperative placement has the potential benefits of more accurate plane targeting, time saving, and widening the scope of use to practitioners are not trained in the ultrasound guided technique. We also present a review of the regional block techniques and present a preliminary algorithm for the selection of block method in breast surgery.

Octogenarians develop infrapopliteal arterial occlusive disease in the absence of traditional risk factors.

BACKGROUND: With increasing longevity, a growing proportion of patients who present with lower extremity peripheral arterial disease (LE-PAD) are ≥80 years old. While smoking and diabetes mellitus (DM) have traditionally been the main risk factors associated with PAD, we noted a pattern of severe infrapopliteal PAD in patients ≥80 years old in the absence of these traditional risk factors. As recognition of patterns of disease affects decisions regarding diagnostic and therapeutic approach, we sought to confirm this observation. METHODS: A single-center retrospective review was performed on all patients who underwent lower extremity arteriography between March 2007 and September 2009. Arteriograms were scored in a blinded fashion. Any infrapopliteal PAD was defined as one or more infrapopliteal arteries with either >50% stenosis or total occlusion. Severe infrapopliteal PAD was defined as 2 or more infrapopliteal arteries with >50% stenosis or total occlusion. Fisher's exact test and 2-sample t-test or Wilcoxon rank-sum test were used for analysis. RESULTS: Two hundred ninety-seven patients comprised the study population. Eighty-two percent (= 145/176) of those ≤70 years old versus 96% (= 46/48) of those ≥80 years old had any infrapopliteal PAD (P = 0.02). Thirty percent of patients ≥80 years old with infrapopliteal PAD had no history of DM or smoking, while only 5% of younger patients had infrapopliteal PAD in the absence of DM or smoking (P < 0.0001). A similar pattern was seen for severe infrapopliteal PAD. Tissue loss was an indication for lower extremity arteriography in 45% of those ≤70 years of age versus 65% of those ≥80 (P = 0.022). CONCLUSIONS: A significant proportion of patients ≥80 years of age with PAD develop arterial disease in the infrapopliteal pattern in the absence of the traditional risk factors of smoking and DM. Our data also showed that this pattern of disease is significantly associated with tissue loss and critical limb ischemia, particularly in patients ≥80 years of age. Primary care providers need to be educated to suspect ischemic etiology for foot pain and ulcers in elderly patients not otherwise thought to have risk factors associated with PAD. Vascular specialists need to anticipate this pattern of disease when planning interventions. As smoking becomes less prevalent and as the population ages, octogenarians with severe infrapopliteal arterial occlusive disease will become a larger proportion of the patients treated by vascular specialists.

Successful treatment of an iatrogenic right hepatic artery pseudoaneurysm and stenosis with a stent graft.

A 53-year-old woman presented with an iatrogenic right hepatic artery pseudoaneurysm after a laparoscopic cholecystectomy. Approximately 1 year after the cholecystectomy, liver transaminases were elevated, and she complained of recurrent "crampy" right upper quadrant pain that radiated posteriorly to her back. Imaging studies demonstrated an aneurysm or pseudoaneurysm of the hepatic artery at the porta hepatis, with possible infiltration into the parenchyma between the right and left lobes of the liver. Selective celiac arteriography showed a 90% stenosis of the right hepatic artery with a large pseudoaneurysm arising from the stenotic segment. This was treated with a 3- x 16-mm stent graft (Jostent; Abbott Vascular, Temecula, Calif) with good result. The completion arteriogram showed wide patency of the stent graft with total exclusion of the pseudoaneurysm. Follow-up serial duplex scans up to 40 months after the procedure showed no evidence of residual pseudoaneurysm and wide patency of the stent graft, with no evidence of focal velocity changes in the right hepatic artery. The patient continues to do well clinically.