Awake mastectomy in a patient with severe cardio-respiratory disease

Regional anaesthesia to facilitate awake mastectomy is increasingly recognised as a viable alternative for patients in whom general anaesthesia presents significant risk. This case report describes a successful total mastectomy in a patient with secondary angiosarcoma and multiple complex comorbidities. The planned regional anaesthetic technique included multilevel transverse paravertebral blocks, pecto-intercostal fascial plane blocks and a supraclavicular brachial plexus block. The intricate sensory innervation of the breast, anterior chest wall and axilla present considerable challenges to achieving adequate anaesthesia; these are explored in detail, with emphasis on the necessity of an individualised approach which accounts for both patient-specific and surgical factors. Sedation is commonly employed to enhance patient comfort during awake procedures; however, pharmacological selection and administration may be complicated in patients with pulmonary hypertension, as illustrated in this case. The patient experienced optimal conditions for surgical resection and reported a positive peri-operative journey, from pre-assessment to hospital discharge. A reflective account of the patient's experience is included. This case, in conjunction with existing literature, supports the broader implementation of awake mastectomy as a feasible and patient-centred option in appropriately selected individuals.