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The adductor canal block (ACB) aims to anesthetize numerous nerves, including the saphenous nerve, for postoperative analgesia for lower extremity surgery. The superficial femoral artery (SFA) and sartorius muscle are critical sonographic landmarks for this block. While performing an ACB in a patient with a history of femoral-popliteal bypass grafting (who consented to publication of this report), the large, pulsatile lumen of the bypass graft deep to the sartorius muscle was initially misidentified as the native SFA (Figure, panels A, B). Nevertheless, when scanning proximally and distally, the pulsatile structure’s relationship to the sartorius muscle failed to change as expected (from the posterior aspect of the muscle proximally to the anterior aspect distally). After increasing the ultrasound depth, less intense colour-flow Doppler signals were observed deep to the graft. Proximal and distal scanning of these structures revealed them to be the native SFA and superficial femoral vein (Figure, panels C, D). This facilitated successful ACB, providing excellent postoperative analgesia.
Large pulsatile structure identified as femoral-popliteal bypass graft (gold) deep to sartorius muscle (pink) (panels A, B). Native SFA (red), SFV, and saphenous nerve (yellow) visualized with increased ultrasound depth (panels C, D).
N = saphenous nerve; SFA = superficial femoral artery; SFV = superficial femoral vein
Anesthesiologists should be familiar with both the normal anatomy and congenital or acquired variations for the blocks they perform. The presented images represent a reverse autologous graft with tunnelling deep to the sartorius muscle. Nevertheless, the sonographic appearance will likely differ dramatically with graft type (autologous, in situ, synthetic), tunnelling path, and surgical technique. Thus, it is critically important for the anesthesiologist to understand the surgical approach used during a previous femoral-popliteal bypass graft and comprehensively scan with ultrasound before performing an ACB in the setting of a prior femoral-popliteal bypass graft.
Disclosures
Dr. Vitug and Mr. Meller have no disclosures to report. Please see below funding statement for disclosures pertaining to Dr. Finneran.
Funding statement
The University of California has received funding and product for the research of Dr. Finneran from Epimed International (Dallas, TX, USA); infusion pump manufacturers InfuTronix (Natick, MA, USA) and Avanos (Alpharetta, GA, USA); and manufacturers of peripheral nerve stimulation devices SPR Therapeutics (Cleveland, OH, USA) and Masimo (Irvine, CA, USA).
Prior conference presentations
This report was previously presented at the 48th Annual Regional Anesthesiology and Acute Pain Medicine Meeting (20–22 April 2023, Hollywood, FL, USA) and the 60th Annual Western Anesthesia Resident’s Conference (31 March–1 April 2023, Scottsdale, AZ, USA).
Editorial responsibility
This submission was handled by Dr. Vishal Uppal, Associate Editor, Canadian Journal of Anesthesia/Journal canadien d’anesthésie.
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Vitug, S.J., Meller, L.L.T. & Finneran, J.J. Femoral-popliteal bypass graft: a caveat when performing an adductor canal block. Can J Anesth/J Can Anesth (2023). https://doi.org/10.1007/s12630-023-02614-z
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DOI: https://doi.org/10.1007/s12630-023-02614-z