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Leg Bypass Surgery

Femoropopliteal and femorodistal bypass
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).

A synthetic tube is used for an aorto-bifemoral bypass because the arteries are large.  When the bypass operation is required in the leg, then the best material to use is a piece of vein (great saphenous vein) removed from the patient’s own leg.  When vein is used, the long term success of the operation is greater and the risk of infection lower.  If there is no suitable vein in the leg, then vein from the arm can be used in some patients.  If there is no vein available to use, then the bypass can be performed with a synthetic tube (graft) but the long term results are not as good.

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 can be given.  The operation can be done either under a general anaesthetic or an epidural anaesthetic which involves an injection in your back to make you numb from the waist down. Your surgeon and anaesthetist will talk to you about which sort of anaesthetic might be best. A catheter will usually be inserted into your bladder to drain any urine and extra drips may be placed in your wrist and neck to monitor your heart function and provide fluids during and after the operation.

The surgery starts with an incision being made in the groin to expose the femoral artery above the blockage. A second incision is made further down the leg to expose an artery below the blockage (the popliteal artery near the knee or an artery in the calf).  A length of vein (usually the great saphenous vein) is then removed to be used for the bypass.  If this vein is unavailable, then a vein from the other leg or arms maybe used.  If there is no suitable vein, then a synthetic tube made of Dacron or PTFE (polytetrafluoroethylene) is used instead.  The vein or synthetic graft is then stitched to the femoral artery in the groin and the artery further down the leg to bypass the blocked arteries. Once the graft has been stitched into place, the incision is then closed with stitches or metal clips which will be removed around 10 days after the operation.

After the operation
You will usually return to the ward where the staff will keep you under close observation.  After a few hours you will be given something to drink, and may be given some food. 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 4-7 days until you are discharged from hospital.

Complications of surgery
A femoro-popliteal or femoro-distal bypass operation is major surgery and about 1 in 20 (5%) 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.
  • Leg swelling – some leg swelling occurs in virtually all patients after the operation.  This resolves over the following weeks in the majority of patients
  • Skin numbness – some areas of skin numbness will occur due to the inevitable cutting of nerves when the incisions are made to perform the surgery.  At first this can be very noticeable but often fades in time.  In the longer term, it is not usually a problem for the vast majority of patients.
  • 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.
  • Stroke – this is rare.
  • Loss of blood supply to the legs – this may occur due to kinking of part 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.
  • Infection of the synthetic graft – 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. 

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 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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