Femoropopliteal and Femorodistal Bypass

The femoral artery starts in the lower abdomen and runs down into the thigh. This artery delivers blood to your legs. When the femoral artery reaches the back of the knee it becomes the popliteal artery. When there is a blockage in this artery, the circulation of blood to your leg is reduced which may cause pain in your calf when you walk and is known as intermittent claudication.

This operation should allow you to walk further without pain. This surgery is also recommended when the circulation is so poor that your foot is painful at rest or at night. Another symptom indicating a possible blockage in the artery may be leg ulcers or black areas of dead skin. In such cases, this operation can be used to prevent the amputation of your leg below or above the knee.

A femoral-popliteal bypass is an operation to bypass the blocked portion of the artery in the leg using a piece of another blood vessel.

Before your operation

Before bypass surgery, there are a number of tests that need to be done. These are of two types: those to assess your general fitness and those to assess your suitability for different types of bypass surgery.

Tests of fitness and suitability are normally done before a decision to operate is made. They normally include:

• Blood tests
• An ECG
• A CT scan of the blocked artery
• Ultrasound assessment of the vein which will normally be used to perform the bypass

These immediate pre-operative tests are usually completed at a pre-admission visit to the hospital a few days before your operation. They may sometimes be done when you are admitted for the operation. Sometimes, the course of the vein to be used for the bypass will be marked in your leg with an indelible pen. This marking is done with the assistance of ultrasound.

Coming into hospital

Please bring with you all the medications that you are currently taking. You will be admitted to your bed by one of the nurses who will also note down your personal details in your nursing record. You will be visited by the Surgeon who will be performing your operation and also the doctor who will give you the anaesthetic. If you have any questions regarding the operation please ask the doctors.

The Operation

The blocked artery must be exposed both above and below the blockage. A vertical incision about 10cm (4inches) long is made in the groin to expose the common femoral artery. This is the main artery supplying the leg and is usually the point from which the bypass starts. A second incision of similar length is made to expose the artery below the blockage. This may be just above or below the knee and is on the inner side of the leg. Occasionally, the incision is lower in the calf, and may then be on either side.

The tube used to perform the bypass will normally be the principal skin vein of the leg. It is called the long saphenous vein and it runs up the inner side of the leg from ankle to groin. Helpfully, the vein lies in the line of the incisions used to expose the artery. Sometimes the vein can be removed with the addition of another small incision about 5cm long at mid-thigh level. Sometimes the two main incisions are joined to make one long incision. If the long saphenous vein is unavailable, its counterpart in the other leg or a vein from the arm may be used instead.

If no vein is suitable, an artificial tube is used. This is made of plastic and may be one of several types. The bypass tube is joined to the artery at groin level and again to the artery below with very fine permanent stitches. The graft will sometimes lie deep within the leg, and sometimes just beneath the skin. If it is beneath the skin (in situ vein bypass) the pulse in it can easily be felt. At the end of the operation, the incisions are all closed, either with dissolving stitches, which do not need to be removed or with a non-dissolving stitch or metal clips which will normally be removed after about ten days.

The Operation

After your operation, you will be given fluids by a drip in one of your veins until you are well enough to sit up and take fluids and food by mouth. It is likely that you will experience bruising around the area operated on.

After your operation, you will be given fluids by a drip in one of your veins until you are well enough to sit up and take fluids and food by mouth. It is likely that you will experience bruising around the area operated on.

You may be visited by physiotherapists after your operation. They will help you with your breathing to prevent you from developing a chest infection and with your mobilisation to get you walking again.

You may be given aspirin (or in some cases warfarin) to reduce the risk of your bypass blocking. This will usually be continued indefinitely.

Going home and aftercare

You may feel tired for some weeks after the operation but this should gradually improve as time goes by. Most people are back to work six weeks after the operation. Please ask staff if you require a sick certificate for work and this will be given to you before you leave the hospital. You should be able to gradually resume normal activities when you feel well enough. Avoid heavy lifting and frequent stretching at first. Regular exercise such as a short walk, combined with rest is recommended for the first few weeks following surgery, followed by a gradual return to your normal activity.

Driving:

You will be safe to drive when you are able to perform an emergency stop. This will normally be 2-4 weeks after surgery, but if in doubt check with your own doctor.

Bathing:

Once your wound is dry you may bathe or shower as normal.

Work:

If this applies to you, you should be able to return to work within 6-12 weeks of surgery.

Medicines:

You will usually be sent home on a small dose of aspirin if you were not already taking it. This is to make the blood less sticky. If you are unable to tolerate aspirin, an alternative drug may be prescribed.

Complications

Chest infections:

These can occur following this type of surgery, particularly in smokers, and may require treatment with antibiotics and physiotherapy.

Wound infection:

Wounds sometimes become infected and this may need treatment with antibiotics. Bad infections are rare. Occasionally, the incision may need to be cleaned out under anaesthetic.

Graft infection:

Very rarely (about 1 in 500), the artificial graft may become infected. This is a serious complication, and usually, treatment involves removal of the graft.

Fluid leak from the wound:

Occasionally the wound may leak fluid. This may be clear but is usually bloodstained. It normally settles in time and does not usually indicate a problem with the bypass itself.

Bowel problems:

Occasionally the bowel is slow to start working again after the operation. This requires patience and fluids will be provided in a drip until your bowels get back to normal.

Major complications:

As with any major operation, there is a small risk of you having a medical complication such as a heart attack, stroke, kidney failure, chest problems, loss of circulation in the legs or bowel, or infection in the artificial artery. Each of these is rare, but overall it does mean that some patients may have a fatal complication from their operation. For most patients this risk is about 5% – in other words, 95 in every 100 patients will make a full recovery from the operation. The doctors and nurses will try to prevent these complications and to deal with them rapidly if they occur.

Bypass blockage:

The main specific complication of this operation is blood clotting within the bypass causing it to block. If this occurs it will usually be necessary to perform another operation to clear the bypass.

Limb loss:

Very occasionally when the bypass blocks and the circulation cannot be restored, the circulation of the foot is so badly affected that amputation is required.

Limb swelling:

It is normal for the leg to swell after this operation. The swelling usually lasts for about 2-3 months. It normally goes virtually completely, but may occasionally persist indefinitely.

Skin sensation:

You may have patches of numbness around the wound or lower down the leg which is due to the inevitable cutting of small nerves to the skin. This can be permanent but usually gets better within a few months.

What can I do to help myself?

If you were previously a smoker you must make a sincere and determined effort to stop completely. Continued smoking will cause further damage to your arteries and your bypass is more likely to stop working. General health measures such as reducing weight, a low-fat diet and regular exercise are also important.