45-year-old male, with no known drug allergies. Personal history: ex-smoker (more than 30 packs/year), type 2 diabetes mellitus, hypercholesterolemia, a history of circulating antiphospholipid antibody with a history of two deep vein thrombosis. Within his pre-admission vascular history: in October 2004 he had a left iliac stent plus a left-right femoral-femoral by-pass. In February 2005 he underwent dilatation with cryotherapy of the left iliac, which was not effective, so he underwent a femoro-popliteal by-pass to the first portion of the left lower limb.
In February 2006 he was admitted again to the vascular surgery department due to short claudication. In a first operation, a bilateral femoral-ileal by-pass was performed with placement of an epidural catheter for post-surgical analgesia. The postoperative period was not satisfactory, so three days later, a new operation was performed: common femoral by-pass with internal saphenous vein in the left leg. After 24 hours of evolution, the epidural catheter was lost and intravenous analgesia was prescribed at that time. Four days later the evolution was not adequate, with an ischaemic foot, cold toes, signs of prenecrosis, together with intense pain requiring treatment with transdermal fentanyl, rescue with 5 mg boluses of subcutaneous morphic chloride every hour and oral corticoids (prednisone 60 mg/day), suspecting the possibility of small vessel micro-infarcts and considering the possibility of amputation of the anterior third of the foot, given the bad situation. Consultation with the anaesthesiology department (Pain Unit) was requested, which rejected the placement of a new epidural catheter, as the patient was on therapy with oral anticoagulants. It was decided to place a sciatic catheter (Stimulong-plus Plexos Cateter set 19 G-100 mm by Pajunk®), which was performed in the operating theatre, with neurostimulation and via the proximal posterior gluteal route (Labat technique). Perfusion with bupivacaine 0.37 % at 3-5 ml/hour is then started. Two days later the foot looks much better. Six days after catheter placement she began to walk, losing the sciatic catheter three days later, at which point she was switched to intravenous analgesia. She was discharged 2 days later with a satisfactory evolution.