Lower Limb Bypass Surgery

 

Lower limb bypass surgery is used for patients with a long blockage of one or more arteries of the leg. The operation is performed via an incision in the leg and involves sewing a bypass graft (usually your own vein, but sometimes a synthetic graft) on to good artery above the blockage and good artery below the blockage. This provides an alternative route for the blood to flow freely around the blockage, and in to the lower leg and foot.

Minimally-invasive endovascular treatment ( angioplasty +/- stenting) is preferred for narrowings or short blockages in the arteries. Bypass surgery is preferred over endovascular repair for long blockages in the arteries. For these lesions, bypasses are more durable in the long-term.

 

Preparing for the Procedure:

Prior to leg bypass surgery, accurate imaging of the arteries is required to plan for surgery. This will start with a duplex ultrasound of the leg arteries, and is followed by a diagnostic catheter-directed angiogram (where dye is injected in to the blood under X-ray to reveal the precise anatomy).

A baseline set of blood tests will be done.  Some patients require an echocardiogram (ultrasound of the heart) and/or respiratory (lung) function tests. If Mr Milne has concerns about your anaesthetic, you will be seen by an anaesthetist before the operation for assessment and review of all test results.

Unless otherwise specified, all regular medications are continued prior to the procedure. Mr Milne will give you specific instructions regarding anti-platelet medications (e.g. aspirin and clopidogrel), anti-coagulant medications (e.g. warfarin and Rivaroxaban), and any medications taken for diabetes.

Bring a small suitcase with you to the hospital in preparation for a four to five night stay.

 

Description of the Procedure:

The procedure is performed under general anaesthetic.

An incision is made over the target vessels for the bypass (e.g. in the groin and lower thigh). If your own vein is being used as the bypass material, it is usually exposed via an incision in the thigh. Occassionally, vein from one or both of the arms is used for the bypass, but if required, this will be discussed with you prior to the procedure. The vein is exposed and prepared. The target arteries for the bypass are dissected.

Clamps are used to control the intended 'inflow' artery above the blockage. The top end of the bypass graft is sewn on to the artery. The clamps are released and the graft checked for haemostasis. The intended 'outflow' artery below the blockage is then controlled, and the bottom end of the bypass graft is sewn on to the artery. All clamps are then released to allow the blood to flow to the lower leg and foot, and the graft is checked for haemostasis.

The incisions are then closed with layered sutures, and the skin is closed with a dissolvable stitch underneath the skin. A drain may be left in one or both incisions, and this is usually removed after 24 hours.

 

Following the Procedure:

You will be transferred to the vascular ward for monitoring after the procedure. You may eat and drink after 4 hours.

On the first day after the procedure, you will be sore along the incision line in the leg. Pain relief will be given to minimise this and you will be encouraged to sit out of bed and walk to and from the toilet.

Over the following days, you will be encouraged to walk more and more.

The aim for discharge from hospital is roughly four to five days after the procedure. Occasionally, a longer stay is required if issues have arisen. 

You will be scheduled for a review appointment with Mr Milne 4 6 weeks after the procedure. A duplex ultrasound of the bypass graft will be performed at the same visit.

After this, you will be reviewed at 3 months, 6 months and 12 months post-operatively. After this, an annual check with an ultrasound is required to check that the graft is flowing well.

 

Travel:

It is generally advised to wait at least 4 weeks before driving a motor-vehicle following leg bypass surgery.

You may travel short distances, under 4 hours, 4 weeks following the procedure. It is ideal to avoid flights/train/car travel over 4 hours duration for 6 weeks following the procedure. It is important to stay hydrated and walk around the cabin regularly whenever flying.

 

Possible Complications of the Procedure:

- Pain/bruising:

• It is normal to experience some pain and bruising along the leg wound.
• You will receive pain-relief medications through the drip initially, then orally. You will be sent home with medications for ongoing pain relief if required.

- Bleeding:

• Even when there is no bleeding at the time of operation, major bleeding can occur from the site of the bypass. This is uncommon (~1%).
• If it occurs, it requires an urgent trip to theatre to fix.

- Infection:

• Antibiotics are given at the time of surgery to minimize the risk of infection.
• The risk of an infection involving the leg wound is ~1 %. This type of infection usually resolves with a course of antibiotics.
• Most often, your own vein is used as the bypass graft. If a synthetic graft is use, there is short and long-term risk of infection (~5%). If this occurs, the bypass graft would likely need to be removed.

- General Complications:

• These are complications that occur away from the site of the procedure. They are a risk to all patients undergoing major surgery of any kind under general anaesthetic.
• They include heart attack, stroke, kidney dysfunction, chest infection, clot in the legs (deep vein thrombosis - DVT) and clot in the lungs (pulmonary embolus - PE).
• If any of these occur, the majority of patients are successfully treated whilst an inpatient, although the length of hospital stay would likely be increased.

- Mortality:

• The risk of dying from complications associated with leg bypass surgery is rare (~1%).
• If you are considered a high-risk patient for surgery, this risk may be increased. Your individual risk will be discussed with you prior to surgery.