The awake axillofemoral bypass.

Aortoiliac occlusive disease is the severe form of peripheral arterial disease requiring complex vascular reconstruction, typically performed under general anesthesia (GA). However, GA carries increased risks in patients with significant comorbidities. We report a case of a 61-year-old male with chronic aortoiliac occlusion, uncontrolled hypertension, sepsis, and heavy smoking, presenting with bilateral limb ischemia and sensory-motor deficits. He underwent axillary-to-bilateral femoral artery bypass and right above-knee amputation under thoracic epidural anesthesia (TEA) combined with peripheral nerve blocks (PNB) and light sedation. A T4-L2 sensory block was achieved with stable hemodynamics throughout the 7-hour surgery, with minor hypotension managed by ephedrine. Postoperative analgesia with continuous epidural bupivacaine-fentanyl infusion and multimodal therapy provides excellent pain control. The patient required only brief ICU monitoring and was transferred to the ward without complications. This case demonstrates the feasibility and safety of TEA with PNB as an alternative to GA in high-risk vascular patients, offering effective anesthesia, hemodynamic stability, and superior pain control while minimizing perioperative risks.