I read with interest the clinical case report of a patient with Takayasu's arteritis in whom an epidural anaesthetic was successfully administered for arthroscopic knee surgery .
While I agree that epidural anaesthesia offers significant advantages over general anaesthesia for patients with Takayasu's arteritis, it may not be the optimal regional anaesthetic of choice. Epidural anaesthesia can be associated with sympathetic block and a subsequent decrease in blood pressure that may be hazardous in a patient with compromised regional circulation because of stenosed arteries . Further, the use of epidural anaesthesia may provide a steal-like phenomenon, which can adversely affect regional blood flow even in the setting of normotensive blood pressure . Due to the possibility of marked regional differences in blood pressure with epidural anaesthesia, these authors  question the safety of this technique without monitoring arterial pressure of both upper and lower extremities. In contrast, the use of intra-articular local anaesthesia does not result in sympatholysis or affect regional blood flow. Arthroscopy under local anaesthesia is simple to perform, has a low failure rate, and requires less technical expertise compared to epidural anaesthesia. The use of local anaesthesia for diagnostic arthroscopy was first reported in the 1970s  and then later advocated for operative arthroscopic knee surgery in the 1980s . The technique used for intra-articular local anaesthesia has been extensively described in the anaesthesia and orthopaedic literature and can be performed by either orthopaedic surgeon or anaesthesiologist. Intra-articular local anaesthesia provides satisfactory operating conditions and a high patient acceptability for a variety of operative knee procedures [6,7]. This technique allows the patient to be awake and alert during the surgical procedure, which is a simple and reliable monitor of cerebral perfusion. In addition, the use of intra-articular analgesics provides for improved patient comfort and allows us to avoid the administration of opioids in the perioperative period . Improved analgesia may provide for better maintenance of blood pressure in the perioperative period, which is advantageous in the anaesthetic management of a patient with Takayasu's arteritis. We have been performing arthroscopy under local anaesthesia for over a decade at our institution and believe it is a safe, reliable, inexpensive and practical alternative to epidural anaesthesia for arthroscopic knee surgery. By allowing the patient to be awake for the procedure and providing for maintenance of perioperative blood pressure, I believe intra-articular local anaesthesia is the regional anaesthetic technique of choice for the patient with Takayasu's arteritis.
S. S. Reuben
Department of Anesthesiology; Baystate Medical Center; Tufts University School of Medicine; Boston, Massachusetts, USA
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