[Reply to the letter to the editor - anesthesia for cesarean delivery in a patient with Klippel-Trenaunay syndrome].

Dear Editor,

Initially, we are grateful for the appreciation of our study. Although spinal block is the gold standard technique for obstetric anesthesia, in the case described by Avelar Teixeira et al. it was decided to perform general anesthesia as justified and described in the discussion section of that article: the patient had Klippel–Trenaunay syndrome (TTS), with a previous history of two anterior cesarean sections under spinal anesthesia with severe bleeding and hemodynamic instability, which required blood transfusion. At clinical examination, she presented with cutaneous hemangiomas mainly in the trunk and lumbar region and no imaging exam had been performed to evaluate the neural axis that could rule out the presence of vascular malformations in this region.

Given this situation and knowing the possibility of cutaneous hemangiomas association with vascular malformations in the neural axis and consequent risk of vascular trauma in the passage of the needle to the medullary canal, which can result in hemorrhage, hematoma, radicular and medullary compression, and permanent neurological injury, the option was for neuraxial block in this patient. This situation differs from the cases described by Gonnella et al. in which patients had negative lumbar spine magnetic resonance imaging for arteriovenous malformations and made spinal block a safe anesthetic option.

Computed tomography angiography of the abdomen showed an irregular uterus with multiple varicose veins and arterial vessels and bilateral periaxial varicose veins, pointing to a major surgery and heavy bleeding, a possible indication of arterial embolization and probable hysterectomy, with the participation of a multidisciplinary team.

Given all the considerable preoperative and perioperative clinical aspects, and as there were no defined anesthetic techniques in the literature regarding anesthetic planning for obstetric patients with TTS, we opted for general anesthesia because we consider it to be the safest technique for the patient in question.

We believe that these cases should be, evaluated individually for the best choice of anesthetic technique, considering all hallmarks found in the spectrum of this syndrome. We are grateful for the letter sent by Gonnella et al., congratulate the authors for their scientific contribution to a rare, extremely relevant topic for obstetric anesthesia.

Conflicts of interest

The authors declare no conflicts of interest.