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Bypass Surgery

Aorto-bifemoral bypass surgery
Atherosclerosis is the build up of fatty deposits (called atheroma) within the wall of the arteries within the body.  When this occurs in the arteries to the legs, it is called peripheral arterial disease.  The narrowing or even blockage of the arteries to the legs can cause a variety of problems depending on how severe it is.  Some patients have no symptoms at all, while others suffer pain on exercise (intermittent claudication).  If the circulation to the legs gets even worse, then persistent pain may be felt in the foot and gangrene may occur. 

One way to improve the circulation to the legs is to perform a surgical bypass around the blockage in the artery.  If the blockage is in the arteries in the pelvis, the bypass needs to run from the aorta in the abdomen (tummy) to the femoral arteries in the groin (an aorto-bifemoral bypass).  If the blockage is in the artery of the thigh, the bypass runs from the femoral artery in the groin down to the popliteal artery behind the knee (a femoro-popliteal bypass).  If the blockage is more extensive, then the bypass may run from the femoral artery in the groin down to the arteries in the calf (a femoro-distal bypass).

Before the operation
Before you attend for surgery you will need to undergo some tests to measure your fitness for surgery.  These tests may include:

  • Blood tests – to check for anaemia, kidney function and blood clotting
  • Chest X-ray – to give a baseline picture of the heart and lungs
  • Electrocardiogram (ECG) – to test the electrical function of your heart
  • Echocardiogram –  an ultrasound scan to test the pumping function of your heart

You will also be asked to attend the preadmission clinic where your test results will be reviewed and you will talk to an anaesthetist about the operation.

The operation
The first part of the operation involves inserting a small drip into the back of your hand through which intravenous drugs are given to place you under a general anaesthetic.  You are also likely to have a small tube placed into your back (called an epidural) to help provide pain relief after the operation.  A catheter will be inserted into your bladder to drain any urine.  There will be extra drips placed in your wrist and neck to monitor your heart function and provide fluids during and after the operation.

During the operation, the surgeon will make an incision in your abdomen (tummy) to reach the aorta and both groins to reach the femoral arteries.  An inverted-Y shaped tube (graft) made out of a synthetic material called Dacron is then stitched to the aorta and femoral arteries to bypass the blocked arteries to the legs.  Throughout the surgery we routinely recycle any spilled blood so it can be given back although some patients still require a blood transfusion.  Once the graft has been stitched into place, your incision is then closed with dissolvable stitches or metal clips which will be removed around 10 days after the operation.

After the operation
You will usually spend 1-2 days in either the High Dependency Unit or Intensive Care Unit where there are specialist staff and equipment to keep you under close observation.  Many patients worry about pain after the surgery and we know that poor pain control is not only miserable for the patient but also slows down recovery and increases the risk of complications.  Therefore, we take great care to try to reduce pain to a minimum and have a variety of techniques to do this such as epidurals and patient controlled morphine pumps.  As you recover, the various drips and tubes will be gradually removed, and you will be moved back onto a normal ward for 7-10 days until you are discharged from hospital.

Complications of surgery
An aortobifemoral bypass is major surgery and 1 in 30 (3%) of patients do not survive.  The actual risk varies from patient to patient and largely depends on the presence of other medical problems such as heart, lung and kidney diseases.  The tests performed before the operation help to identify patients who have these medical problems and so may be at higher risk.  In some cases, medication can be started to help to reduce the risk of complications such as aspirin and statin tablets for heart disease or inhaler treatments for lung disease.  Unfortunately, for some patients, little can be done to lower surgical risk but knowing this helps the patient and surgeon come to a decision about whether surgery should be attempted.

Around the time of surgery, much is done to lower the risk of complications such as giving antibiotics to reduce wound infections, blood thinning injections to prevent deep venous thrombosis and good pain control with physiotherapy to prevent pneumonia.  Despite this, following their surgery, some patients still develop complications.  Some complications are mild and slow recovery for just a short period while others are far more serious.
Possible complications include:

  • Haematoma and bleeding – some blood can collect under the skin after the procedure.  As long as there is no ongoing bleeding this can often just be observed.  Rarely, persistent and extensive bleeding occurs and requires urgent surgery.
  • Pneumonia/chest infection – occurs most commonly in smokers and requires antibiotics and physiotherapy.
  • Heart attack – usually requires drug treatments.
  • Kidney failure – usually recovers spontaneously. Rarely, renal dialysis is required long term.
  • Wound infection – usually only requires antibiotics, occasionally the wound needs to be cleaned out under anaesthetic.
  • Bowel problems – the return of bowel function may be delayed for several days and may require artificial feeding through a vein for a short time. 
  • Stroke – this is rare.
  • Loss of blood supply to the legs – this may occur due to blockage of the graft or from dislodging loose material within the arteries that then passes down into the legs.  This is rare but may require further surgery.  Rarely, amputation may be required.
  • Deep venous thrombosis – may occur despite injection of blood thinning medication.  If it occurs then warfarin treatment for 3-6 months is usually required.
  • Sexual dysfunction – may occur in men due to nerves within the pelvis being unavoidably cut during the surgery.
  • Infection of the Dacron tube – rare and very serious.  Usually requires removal of the synthetic tube.

Once you go home
You will feel tired for the first few weeks following the operation, but this will improve with time.  It is recommended that you take regular short walks with rest in between for the first few weeks.  Not that you are likely to want to but avoid heavy lifting for 6 weeks after the operation.

You will be able to drive again as soon as you can do an emergency stop.  This will usually be 4-6 weeks after the surgery.  Your insurance company are likely to need to be informed of your treatment.

You will be usually be able to return to work 6-12 weeks following surgery.  For further advice about this you can visit your GP.

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