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This surgery involves a long bypass usually between the femoral artery in the groin and one of the three small arteries in the lower leg (the posterior tibial, the peroneal and the anterior tibial). This procedure is mainly done for limb salvage in patients with tissue loss due to extensive arterial disease. Due to the length of this graft and the small size of the recipient arteries, the choice of graft material is very important. Femoral-Distal bypass grafts using vein last much longer than when synthetic grafts are used. In the rare situation where no suitable veins can be harvested, a synthetic graft is used but with an interposition vein "cuff" or "boot" between the synthetic material and the native recipient artery. The procedure is always preceded by angiography. These angiograms are reviewed by the vascular surgeons and radiologists and a plan for surgery is jointly drawn. Shortly before surgery, marking of the leg or arm veins that are to be used as a graft is done using ultrasound scan.
Femoral-distal bypass surgery is mostly done under epidural anaesthesia. General anaesthesia may be needed if arm veins need to be harvested. A urinary catheter is required for this procedure. These procedures are quite complex and can take up to five hours to complete. A good proportion of this time is spent harvesting and preparing the vein conduit. Following anaesthesia and preparation of the field, the predetermined donor and recipient arteries are exposed, and further assessed as to their suitability for the proposed procedure. The preoperatively marked vein or veins are then harvested or in some cases, prepared in situ to be used as a graft. The vein graft is then joined with the donor artery, tunnelled deep in the leg (reversed vein technique) then joined with the recipient artery distally. The graft is then allowed to run and is assessed for any technical problems. If all is well, the wounds are closed and the patient is moved to the recovery bay.
As part of the routine postoperative monitoring, graft patency is assessed on regular basis. Oral intake is usually possible very early following surgery. Over the ensuing few days, the epidural anaesthetic is gradually reduced and eventually removed. The urinary catheter is then removed and patients are allowed to mobilise gradually. Long term anticoagulation may be required after this procedure.
There are a number of possible complications related to this procedure. These can be grouped into graft related, wound related and general complications. As mentioned previously, Femoral-Distal bypass procedures are quite complex and many technical hurdles have to be overcome in order to achieve a successful outcome. Early graft failure can occur shortly after surgery. This will usually manifest as sudden and rapidly progressive deterioration in the blood supply of the affected limb. This complication will require urgent exploratory surgery. Intermediate and late graft failure can occur due to progression of the arterial disease. Graft failure at any stage is associated with a high risk of limb loss (20%). This surgery usually involves extensive incisions in order to harvest the necessary vein length. Wound complications such as infection, bleeding, lymphatic collection, and pain are therefore common (up to 50%). The general complications associated with this procedure include myocardial infarction, chest infection and renal impairment. Cardiac risks and complication are similar to those mentioned under Femoral-Popliteal bypass surgery. In summary, these are 2% mortality and 10% coronary ischaemic events.
Admission: Varied Anaesthetic: Epidural / General Stay in hospital: 10-14 days Removal of sutures: 10-14 days Time off work: 6-8 weeks First follow-up appointment: 6 weeks |
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