| Femoro - Popliteal Bypass
What is it?
The main artery which carries blood down your leg is blocked just above the knee. The calf, foot and toes are starved of blood. This causes pain and can lead to serious infection and loss of the limb. The blocked part of the artery can be bypassed so that blood flows properly again.
You will have a general anaesthetic, and will be asleep for the whole operation. One or two cuts are made in the skin down the inside of the thigh so that the artery above and below the block can be seen. A bypass tube (vascular graft), made of vein (a superficial vein that lies under the skin which is taken if possible from one of your legs at the same time as the bypass operation) or a special plastic, is stitched into the artery above and below the block. The blood then flows down the bypass towards the toes. The skin wound(s) are then closed up. Usually after a week or so you will feel fit enough to leave hospital provided there is someone to look after you and the wounds are healing well.
If you do nothing your lower limb problems will surely get worse. An injection into the nerve in your back that controls the artery will not help. The blocked artery is not suitable for coring out using lasers or X-ray controlled balloons. Antibiotics and other drugs will not help by themselves. An amputation is not something to have done instead of the bypass operation. However, dead tissue may need to be trimmed away after a bypass operation.
Before the operation
Stop smoking and try to get your weight down if you are overweight. (See Healthy Living). If you know that you have problems with your blood pressure, your heart, or your lungs, ask your family doctor to check that these are under control. Check the hospital's advice about taking the Pill or hormone replacement therapy (HRT). Check you have a relative or friend who can come with you to the hospital, take you home, and look after you for the first week after the operation. Sort out any tablets, medicines, inhalers that you are using. Keep them in their original boxes and packets. Bring them to the hospital with you.
On the ward, you may be checked for past illnesses and may have special tests to make sure that you are well prepared and that you can have the operation as safely as possible. Please tell the doctors and nurses of any allergies to tablets, medicines or dressings. You will have the operation explained to you and will be asked to fill in an operation consent form. Many hospitals now run special preadmission clinics, where you visit for an hour or two, a few weeks or so before the operation for these checks.
After - In Hospital
You may be given oxygen from a face mask for a few hours if you have had chest problems in the past. You will have a fine, thin plastic tube in an arm vein to give you a transfusion of blood or salt solution. There may be some discomfort on moving rather than severe pain. You will be given injections or tablets to control this as required. Ask for more if the pain is not well controlled or if it gets worse. A general anaesthetic will make you slow, clumsy and forgetful for about 24 hours. The nurses will help you with everything you need until you are able to do things for yourself. Do not make important decisions during this time. You will most likely be able to get out of bed with the help of the nurses the day after the operation despite some discomfort. You will not do the wound any harm, and the exercise is very helpful for you. The third day after the operation you should be able to spend most of your time out of bed and in reasonable comfort. You should be able to walk slowly along the corridor. By the end of one week the wound should be virtually pain-free. It is important that you pass urine and empty your bladder within 6 to 12 hours after the operation. If you cannot pass urine let the doctors and nurses know and steps will be taken to correct the problem.
The wound has a dressing which may show some staining with old blood in the first 24 hours. You can take the dressing off after 48 hours. There is no need for a dressing after this unless the wound is painful when rubbed by clothing. There may be stitches or clips in the skin. The wound(s) may be held together underneath the skin with stitches that are dissolvable and don’t need to be removed. There may be some purple bruising around the wound which spreads downward by gravity and fades to a yellow colour after two to three days. This is expected and you should not worry about it. There may be some swelling of the surrounding skin which also improves after two to three days. After 7 to 10 days, slight crusts on the wound will fall off. Occasionally minor matchhead sized blebs (blisters) form on the wound line. These settle down after discharging a blob of yellow fluid for a day or so. You can wash as soon as the dressing has been removed. Try to keep the wound(s) area dry until the stitches/clips come out which is usually 10 to 14 days after the operation. If you just have stitches inside the wound(s), try to keep the wound(s) dry for a week. Soap and tap water are entirely adequate. Salted water is not necessary. You will be given an appointment to visit the outpatient department for a check-up about one month after you leave hospital. The nurses will advise about sick notes, certificates etc.
After - At Home
You will feel tired and need to rest two or three times a day for two weeks or more. The wound is likely to be quite uncomfortable for a month or so. You should get back to your normal activities within two months. If you have had infections, ulcers or loss of skin, these parts may take two months or more to heal up. Sometimes further operations are needed to trim them up. At first discomfort in the wound will prevent you from harming yourself by lifting things that are too heavy. After one month you can lift as much as you used to lift before the operation. There is no value in attempting to speed the recovery of the wound by special exercises before the month is out. You can drive as soon as you can make an emergency stop without discomfort in the wound, i.e. after about 10 days. You can restart sexual relations within a week or two, when the wound is comfortable enough. You should be able to return to work within two months or so.
As with any operation that is done under general anaesthetic, there is a risk of complications related to your heart and lungs. The tests that you will have before the operation will make sure that you can have the operation in the safest possible way and will reduce the chances for such complications.
Complications are rapidly recognised and dealt with by the surgical staff. If you think that all is not well, please let the doctors and nurses know. Sometimes there is some bleeding under the wounds which causes more severe bruising. This settles down. However, there is a small chance of severe bleeding in the area of the operation that might require another operation to stop it.
Sometimes the blood in the bypass tube clots. This usually needs a second operation to clear the blockage. Sometimes the arteries further down on one or both legs cannot take the extra flow of blood. The next steps to deal with this will be discussed with you. The worst case scenario is where it has not been possible to restore satisfactory blood supply to the leg in which case you may need an amputation (removal of the diseased part of the leg).
Wound infection is sometimes seen. This settles down with antibiotics in a week or two. It is much more serious if the infection spreads into your bloodstream or if you have a plastic bypass tube that gets infected. If this is the case you will need antibiotics for much longer and it may be that the plastic bypass tube has to be removed to allow the infection to clear. Sometimes fluid builds up under the wounds. This usually settles down after a while.
The wound sometimes gapes and is slow to heal. This gradually settles down.
Aches and twinges may be felt in the wound for up to six months. Occasionally there are numb patches in the skin around the wound which get better after two to three months. The leg may be swollen for one to two months. This gradually gets better.
Late clotting of the graft can occur. You will be given treatment to prevent it and advice to avoid long car and plane journeys without hourly exercise.
The overall results of this operation are very good. If the bypass tube is a vein. it stays open in 75% of cases five years after the operation. If the bypass tube is made of plastic it stays open in 55% of cases five years after the operation and patients enjoy a good quality of life.
The operation is routine in many hospitals. However, as with all operations in blood vessels it should not be underestimated. You must not smoke, because vascular graft failure is almost certain if you do. These notes should help you through your operation. They are a general guide. They do not cover everything. Also, all hospitals and surgeons vary a little. If you have any queries or problems, please ask the doctors or nurses.
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