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Popliteal Sciatic Nerve Block as Rescue Therapy in Acute Lower Limb Ischemia Related to Venoarterial ECMO Support

  • Sylvain Diop
    Correspondence
    Address correspondence to Sylvain Diop, Département d'Anesthésie et Réanimation, Hôpital Marie Lannelongue, 133 Avenue de la Résistance, 92350 Le Plessis Robinson, France.
    Affiliations
    Cardiothoracic Intensive Care Unit, Marie Lannelongue Hospital, Le Plessis Robinson, France

    Department of Anesthesiology, Marie Lannelongue Hospital, Le Plessis Robinson, France
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  • Maxime Djebbour
    Affiliations
    Cardiothoracic Intensive Care Unit, Marie Lannelongue Hospital, Le Plessis Robinson, France
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  • François Stéphan
    Affiliations
    Cardiothoracic Intensive Care Unit, Marie Lannelongue Hospital, Le Plessis Robinson, France

    University Paris-Saclay, Kremlin-Bicêtre, France

    INSERM U999, Pulmonary Hypertension: Pathophysiology and Novel Therapies, Marie Lannelongue Hospital, Le Plessis-Robinson, France
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  • Thibaut Genty
    Affiliations
    Cardiothoracic Intensive Care Unit, Marie Lannelongue Hospital, Le Plessis Robinson, France
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Published:September 24, 2022DOI:https://doi.org/10.1053/j.jvca.2022.09.086
      To the Editor:
      We would like to share our experience regarding the use of regional anesthesia as an additional therapy in the intensive care unit for acute lower limb ischemia. A 40-year-old, 60-kg, 156-cm woman underwent lung transplant using right femoral venoarterial extracorporeal membrane oxygenation (ECMO) support for preoperative respiratory failure and right ventricle dysfunction related to pulmonary hypertension. Six days after surgery, the patient developed right lower limb ischemia downstream to the ECMO insertion site due to reperfusion cannula malfunction. The clinical improvement of cardiac and respiratory function allowed us to withdraw the ECMO support and perform a right superficial femoral artery embolectomy with a Fogarty catheter. Unfortunately, the right leg remained ischemic. Vascular ultrasound showed a major reduction of the right main tibial artery caliber, with an attenuated pulse-wave Doppler velocity (Fig 1, A and B). To improve perfusion, we performed a right popliteal sciatic nerve block with 15 mL of 0.475% ropivacaine under United States guidance. After the block, perfusion of the right leg was visibly improved. Vascular ultrasound showed a significant increase of the right main tibial artery caliber and pulse-wave Doppler velocity (Fig 1, C and D).
      Fig 1
      Fig 1Before popliteal sciatic nerve block: (A) Vascular ultrasound of the right tibial artery showing a narrow caliber of 22 mm. (B) Right tibial artery pulse-wave Doppler velocity showing an attenuated flow. Thirty minutes after popliteal sciatic nerve block: (C) Increased diameter of the right tibial artery measured at 67 mm. (D) Increase of the right tibial artery pulse-wave Doppler velocity.
      Lower acute limb ischemia is a major concern in patients undergoing venoarterial ECMO support.
      • Bonicolini E
      • Martucci G
      • Simons J
      • et al.
      Limb ischemia in peripheral veno-arterial extracorporeal membrane oxygenation: a narrative review of incidence, prevention, monitoring, and treatment.
      This was the second time in our practice that we successfully used a peripheral nerve block in a context of limb ischemia. We suggest that regional anesthesia could be a useful intervention after the primary cause of ischemia is treated (in this patient, after withdrawal of the ECMO cannula and arterial embolectomy).

      Conflict of Interest

      None.

      Reference

        • Bonicolini E
        • Martucci G
        • Simons J
        • et al.
        Limb ischemia in peripheral veno-arterial extracorporeal membrane oxygenation: a narrative review of incidence, prevention, monitoring, and treatment.
        Critical Care. 2019; 23: 266