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Once one of the commonest vascular procedures, nowadays femoropopliteal bypass surgery is much less frequently performed. This is mainly due to better understanding of the natural history of peripheral arterial disease and to the introduction of effective minimally invasive alternatives such as transluminal or subintimal angioplasty. An angiogram will be required before surgery in order to help design the procedure. Femoral-Popliteal bypass surgery involves creating a bypass between the femoral artery in the groin and the popliteal artery above or below the knee. As with all types of bypass, the patient's own vein provides the best graft material particularly when the recipient artery is the below knee part of the popliteal. Alternatively, and in absence of a suitable vein, a synthetic graft can be used.
These procedures are almost always done under epidural anesthesia. A urinary catheter is therefore required. The extent and orientation of the incisions for this procedure will be determined by the choice of graft. A vein graft will require longer and more numerous incisions to allow for vein harvesting. A synthetic bypass will only require two relatively small incisions at both ends of the bypass. After exposing the arteries, special clamps are positioned to stop the blood flow. The proposed proximal and distal sites of the bypass are then opened and the relative arteries assessed for their suitability. Having harvested and prepared the vein or chosen the appropriate synthetic graft, the surgeon will position the graft deep in the leg and will join the two ends of the graft to the corresponding arteries. The clamps are then removed and the blood allowed to pass through the new bypass. The blood flow in the distal leg is then assessed and if all is well, the wounds are closed and the patient transferred to the recovery bay.
After the initial recovery, patients are usually transferred back to their original wards. Early oral intake is usually allowed. The urinary catheter will remain in situ until the epidural anaesthetic is removed in two to three days. During this period, patients will not be able to mobilise. Once the epidural catheter is removed, gradual mobilisation is allowed with the help of the physiotherapy team. If all goes well, patients are usually allowed home in 7 to 10 days.
Bypass surgery is usually performed at a point where peripheral arterial disease is quite advanced. Patients requiring this type of surgery are therefore very likely to have atherosclerotic arterial disease elsewhere. It is estimated that up to 70% of patients requiring peripheral bypass surgery will have significant coronary artery disease. Post operative cardiac complications are therefore common, being the main cause of the 2% mortality associated with this surgery. In addition, up to 10% of patients will suffer from an ischaemic cardiac event in the few days following surgery. Other complication include graft failure, haemorrhage and infection. Wound infection rate is particularly high (up to 19%). This is mainly a reflection of the poor tissue perfusion and the extensive dissection involved. Finally, in 10% of patients this procedure will fail to preserve the limb and amputation will therefore be required.
Admission: Variable Anaesthetic: Spinal-Epidural Stay in hospital: 7-12 days Removal of sutures: 10-14 days Time off work: 6-8 weeks First follow-up appointment: 6 weeks |
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