Successful use of spinal anesthesia in a patient with severe Klippel–Trénaunay syndrome associated with upper airway abnormalities and chronic Kasabach–Merritt coagulopathy

Anesthetic management of external iliac artery transection in a morbidly obese patient with Klippel-Trenaunay-Weber syndrome: a case report

BACKGROUND

We report the anesthetic management of an external iliac artery transection in a morbidly obese patient with Klippel-Trenaunay-Weber syndrome (KTWS).

CASE PRESENTATION

A 47-year-old man with KTWS was scheduled for a right external iliac artery transection. Preoperative CT showed a right external iliac artery aneurysm, a right superficial femoral artery aneurysm, and developed collateral vessels. General anesthesia was maintained with desflurane, remifentanil, and rocuronium bromide. After the transection of the right external iliac artery, the regional saturation of oxygen (rSO₂) value of the right femoral did not decrease. There was no significant hemodynamic change before or after the transection. A non-ultrasound-guided rectus abdominis sheath block was performed due to the many collateral vessels. After extubation, the patient did not complain of postoperative pain.

CONCLUSIONS

In the transection of lower-extremity blood arteries under laparotomy in patients with KTWS, rSO₂ monitoring, hemodynamic monitoring, and combined regional anesthesia could be useful.

Anesthestic management of Kassabach-Meritt Phenomenon in an adult: case report

Background

Kasabach-Merritt phenomenon (KMP) is characterized by a vascular tumor with profound thrombocytopenia and consumptive coagulopathy that may presents significant challenges for anesthesiologist.

Case presentation

An 87-year-old man presented with kaposiform hemangioendothelioma involving the right leg in critical condition due to massive bleeding. Hematology investigations indicated the presence of KMP. Association of this type of tumor with KMP in adults has never been reported.

Conclusion

The present case report lays an emphasis on the potential difficulties during anesthetic management of this rare condition.

Total knee arthroplasty in vascular malformation

In Klippel-Trenaunay syndrome, vascular malformations are not only in skin and superficial soft tissues but also in deep tissues like muscles bones and joints. It is well documemted that these recurrent intraarticular bleeds can cause early arthritis and joint pain. Performing arthroplasty in such patients is difficult and fraught with complications. We describe such a case where navigated total knee arthroplasty was performed with success to avoid the problems of intra medullary alignment used in the presence of intra medullary vascular malformations. We also suggest certain measures when knee arthroplasty is considered in such patients.

Klippel-Trenaunay syndrome: a rare cause of disabling pain after a femoral fracture

Klippel-Trenaunay syndrome (KTS) is characterized by a cutaneous vascular nevus of the involved extremity, as well as bone and soft tissue hypertrophy of the extremity and venous malformations. We present the case of a 52-year-old man with a femoral fracture and a history of haemangiomas, limb bone hypertrophy and varicosity. The patient was finally diagnosed with KTS and treated in mini-invasive surgery by endomedullary fracture nailing in general anaesthesia. Clinical management was particularly demanding, not only because of the need to monitor the risk of haemorrhage and thrombosis but also because of the onset of a rare picture of neuropathic pain with hyperalgesia and allodynia, never previously reported in patients affected by KTS, that required the administration of major opioid drugs. According to our knowledge, this is the second case of KTS managed for femoral fracture. Unlike the previous report in literature, in this case a severe disabling neuropathic pain complicated the clinical management.

Neuraxial techniques in patients with pre-existing back impairment or prior spine interventions: a topical review with special reference to obstetrics

Many anaesthetists consider neurological disorders of all kinds as a contraindication for regional anaesthesia particularly for neuraxial techniques. This hesitation is partly rooted in fears of medicolegal problems but also in the heterogeneous literature. Therefore, the present topical review is an attempt to describe the feasibility and the risks of neuraxial techniques in patients with spinal injury, anatomical compromise, chronic back pain or previous spinal interventions, ranging from 'minor' types like epidural blood patches to major surgery such as Harrington fusions. Most reviews and case reports were describing experiences in obstetrics as these patients are more likely to insist on neuraxial blocks. In the acute phase of new neurologic injury, general anaesthesia may be the technique of choice to prevent further haemodynamic and respiratory deterioration. After the acute phase, current evidence is mostly reassuring with respect to the risks of neuraxial blocks as they may even be recommendable in some conditions. Ultrasound technology may be of additional help to increase the success rate. A careful pre-operative examination remains mandatory, while patients should be sufficiently informed about technical aspects and possible relapses or progression of their disease. When necessary, patients should have additional technical and clinical examinations as close as possible to surgery to establish the actual pre-operative status. Most patients may benefit more from spinal techniques rather than from less reliable epidural ones. High concentrations and volumes of local anaesthetics should be avoided at all times, especially in patients with nerve compression, large disc herniation or spinal stenosis.

Anesthesia for surgery related to Klippel-Trenaunay syndrome: a review of 136 anesthetics

BACKGROUND

Klippel-Trenaunay syndrome (KTS) is a rare congenital malformation characterized by the triad of varicose veins or venous malformations, capillary malformations that may involve neurovascular structures, and bony or soft tissue hypertrophy in affected limbs. Areas such as the trunk, bowel, bladder, and spinal cord may be involved as well. KTS should not be confused with Klippel-Feil syndrome, which involves abnormalities of the cervical vertebrae. Anesthetic management for patients with KTS has only been described in limited case reports that caution about potential airway difficulty but do not report surgical hemorrhage requiring transfusion.

METHODS

We performed an electronic search of the Mayo Clinic medical record database to identify patients who had undergone an anesthetic for surgery related to KTS. Review of medical records was performed for type of surgery, anesthetic technique, airway management and difficulty, medications used, intraoperative fluid administration, transfusion requirements, vascular access used, and postoperative complications.

RESULTS

Eighty-two unique patients were identified who underwent 134 general anesthetics and 2 lumbar neuraxial anesthetics for surgeries related to KTS. Preoperatively, 27% of patients had a history of recurrent bleeding, 24% recurrent cellulitis, 9% deep vein thrombosis, and 2% pulmonary embolism. The mean age at time of surgery was 21 ± 15 years. The majority of surgical procedures involved laser coagulation or varicose vein sclerotherapy or stripping. All of the 74 direct laryngoscopies and tracheal intubations were performed on the first attempt without difficulty. Mask ventilation was possible in all 131 patients for whom this was attempted, with only 1 requiring an oral airway. Documented estimated blood loss ranged from 20 to 18,000 mL, with a mean of 740 ± 2739 mL. Use of a tourniquet did not obviate the possibility of substantial blood loss. The only significant postoperative complication involved a calf hematoma after vein stripping and avulsion that required return to the operating room for evacuation.

CONCLUSIONS

Patients with KTS have multiple associated comorbidities relevant to perioperative management. In contrast to previous reports, difficulty with airway management was not encountered. Surgery related to severe KTS may be associated with massive hemorrhage despite tourniquet use, and the anesthesiologist should anticipate the need for appropriate fluid resuscitation. Neuraxial techniques may be considered only if the possibility of trauma to neurovascular malformations has been excluded with recent spine imaging.