Ultrasound-guided costoclavicular approach infraclavicular brachial plexus block for vascular access surgery

Introduction: We report the use of a newly described regional technique, ultrasound-guided costoclavicular approach infraclavicular brachial plexus block for surgical anesthesia in two high-risk patients undergoing 2nd stage transposition of basilic vein fistula. Methods: Both patients had features of difficult airway, American Society of Anesthesiologists (ASA) physical status class III and central venous occlusive disease. The common approach, i.e., ultrasound-guided supraclavicular brachial plexus block was technically difficult with inherent risk of vascular puncture due to dilated venous collaterals at the supraclavicular area possibly compromising block quality. The risk of general anesthesia (GA) was significant as patients were morbidly obese with possible risk of obstructive sleep apnea postoperatively. As an alternative, we performed the ultrasound-guided costoclavicular approach infraclavicular brachial plexus block with 20 mL local anesthetic (LA) ropivacaine 0.5% delivered at the identified costoclavicular space using in-plane needling technique. Another 10 mL of LA was infiltrated along the subcutaneous fascia of the proximal medial aspect of arm. Results: Both surgeries of > 2 hours' duration were successful, without the need of further local infiltration at surgical site or conversion to GA. Conclusions: Ultrasound-guided costoclavicular approach can be an alternative way of providing effective analgesia and safe anesthesia for vascular access surgery of the upper limb.