The femoral artery begins in the lower abdomen and extends to the thigh. This artery supplies blood to your legs. When the femoral artery reaches the hollow of the knee, it becomes the popliteal artery. When this artery becomes blocked, blood flow to your leg is reduced, which can cause calf pain when you walk. This is known as intermittent claudication.
This surgery should allow you to move on without pain. This surgery is also recommended if blood circulation is so poor that your foot is painful at rest or at night. Another symptom that indicates a possible blockage in the artery can be leg ulcers or black areas of dead skin. In such cases, this surgery can be used to prevent amputation of your leg below or above the knee.
Femoral popliteal bypass is an operation used to bypass the blocked part of the artery in the leg with a piece of another blood vessel. The following information explains the process of femoral popliteal bypass.
Before your surgery
Some tests need to be done prior to bypass surgery. There are two types: one to assess your general fitness and one to assess your suitability for different types of aneurysm surgery.
Fitness and aptitude tests are usually done before a decision is made to operate. They usually include:
Blood tests
An EKG (electronic heart monitoring)
An ultrasound scan of the blocked artery
Ultrasound scan of the blocked artery
Ultrasound scan of the vein, usually used to perform the bypass
Immediate preoperative tests include: blood tests, another EKG, and paperwork filling out. These immediate preoperative tests are usually done during a visit to the hospital a few days before your surgery. They can sometimes be done if you are approved for the surgery. Sometimes the course of the vein to be used for the bypass will be marked in your leg with an indelible pencil. This marking is done with the help of ultrasound.
Come to the hospital
Please bring any medication you are currently taking with you. You will be taken to your bed by one of the nurses who will also add your personal information to your medical record. You will be visited by the surgeon who will perform your surgery and also the doctor who will give you the anesthetic. If you have any questions about the operation, please contact the doctors.
Operation – anesthetic
The first part of the operation involves anesthesia. This surgery can be performed while you are sleeping (generally) or while you are awake. If you have general anesthesia, a tiny needle will be inserted into the back of your hand. The anesthetic will be injected through the needle and you will be asleep in seconds. When you’re supposed to be awake, you’ve got a little tube in your back. This is known as the spine or epidural.
With a spinal anesthetic, you cannot feel anything from the waist down on the surgical side. The leg is paralyzed. This anesthetic takes about 2-2½ hours.
With an epidural, you cannot feel anything from the waist down and it affects both legs. However, there is no paralysis. The epidural is like a drop and can be left for several days to provide post-operative pain relief.
A tube (catheter) can be inserted into your bladder to drain your urine when you are under general anesthesia. The catheter is important when you have either the spine or the epidural. For all three options, a drop will be placed in a vein in your forearm to give you some fluid during and after the surgery.
The operation
The blocked artery must be exposed both above and below the blockage. A vertical incision about 10 cm long is made in the groin to expose the common femoral artery. This is the main artery that supplies the leg and is usually the point where bypass begins. A second incision of similar length is made to expose the artery below the blockage. This can be just above or below the knee and is located on the inside of the leg. Occasionally the incision in the calf is lower and can then be on either side.
The tube used to perform the bypass is usually the major cutaneous vein of the leg. It’s called the long saphenous vein and runs down the inside of the leg from the ankle to the groin. Helpful? The vein coincides with the incisions that will expose the artery. Sometimes the vein can be removed by making another small incision about 2 inches long in the middle of the thigh. Sometimes the two main cuts are put together into one long cut. If the long saphenous vein is not available, its counterpart in the other leg or a vein from the arm can be used instead.
The preoperative ultrasound exam of the veins will determine which vein is best. If a vein is not suitable, an artificial tube is used. This is made of plastic and can be one of several types. The bypass tube is connected to the artery at the level of the groin and to the lower artery with very fine endless stitches. The graft is sometimes deep in the leg and sometimes just under the skin. If it is under the skin (in situ venous bypass) the pulse is easy to feel. At the end of the operation, all incisions are closed, either with dissolvable stitches that do not need to be removed or with a non-dissolving stitch or metal staples that are usually removed after about ten days.
After the operation
After your surgery, a drop in one of your veins will give you fluids until you are good enough to sit up and take fluids and food by mouth. The nurses and doctors will try to keep you pain-free by giving pain medication by injection, through the epidural tube in your back, or through a machine that you can control yourself at the push of a button. It is likely that you will get bruises in the area that was operated on.
The drip, epidural and urinary catheters are removed within a day. You will gradually become more mobile until you are fit enough to go home. You can be visited by a physiotherapist after your operation. They help you breathe to avoid a chest infection and mobilize you so you can walk again.
You may be given aspirin (or, in some cases, warfarin) to reduce the risk of bypass obstruction. This usually continues indefinitely.
Before you go home, you will be given an outpatient appointment.
Go home and follow-up care
If your stitches or clips are the type that needs to be removed, it usually happens while you are still in the hospital. If not, we’ll have your GP or district nurse’s office remove it and check your wound. If you swell or leak from the wound at home, see your GP.
You may feel tired for a few weeks after the surgery, but this should gradually improve over time. Most people returned to work six weeks after surgery. Please ask the staff whether you need a medical certificate for work, which will be given to you before you leave the hospital. If you need a longer free time, which is stated on the certificate, your GP can provide you with an additional certificate.
You should be able to gradually resume normal activities when you are feeling well enough. First, avoid heavy lifting and frequent stretching. Regular exercise such as a short walk combined with rest is recommended for the first few weeks after surgery, followed by a gradual return to normal activity.
Driving: You can drive safely if you can perform an emergency stop. This is usually 2-4 weeks after surgery, but if in doubt, consult your own doctor.
Bathing: As soon as your wound is dry, you can bathe or shower as usual.
Work: If this applies to you, you should be able to return to work within 6-12 weeks of the operation. Your GP will let you know when you see him / her about your medical record.
Medicines: You will usually be sent home with a small dose of aspirin if you haven’t already taken it. This is supposed to make the blood less sticky. If you cannot tolerate aspirin, an alternative drug may be prescribed.
Complications
Breast infections: These can happen after this type of surgery, especially in smokers, and may require treatment with antibiotics and physical therapy.
Wound infection: wounds sometimes become infected and may need antibiotic treatment. Bad infections are rare. Occasionally the incision needs to be cleaned under anesthesia.
Transplant infection: Very rarely (around 1 in 500) the artificial transplant can become infected. This is a serious complication and treatment usually involves removing the graft.
Fluid leakage from the wound: Occasionally fluid may leak from the wound. This may be obvious, but it is usually bloody. It usually settles in a timely manner and does not usually indicate a problem with the bypass itself.
Bowel problems: Occasionally, the bowel starts to work slowly after the operation. This requires patience and fluids are provided in a drop until your bowel returns to normal.
Main Complications: As with any major surgery, there is a small risk of medical complications such as heart attack, stroke, kidney failure, chest problems, loss of circulation in the legs or intestines, or artificial arterial infections. Each of these are rare, but overall it means that some patients can experience fatal complications from their surgery. For most patients, this risk is around 5% – in other words, 95 out of 100 patients will recover completely from the operation. The doctors and nurses will try to prevent these complications and treat them quickly if they arise.
Bypass Blockage: The main specific complication of this surgery is bypassing the clotting of the blood, resulting in a blockage. In this case, another operation usually has to be performed to clear the bypass.
Limb Loss: Very occasionally, when the bypass is blocked and blood flow cannot be restored, blood flow to the foot is so impaired that amputation is required.
Swelling of the limbs: It is normal for the leg to swell after this surgery. The swelling usually lasts about 2-3 months. It is usually practically complete, but can occasionally persist indefinitely.
Skin feel: Due to the inevitable cut of small nerves on the skin, numb spots can appear on the wound or on the lower end of the leg. This can be permanent, but usually gets better within a few months.
What can i do to help myself?
If you have been a smoker before, you must make a sincere and determined effort to quit completely. Continuing to smoke will cause further damage to your arteries and, more likely, your bypass will stop working. General health measures like weight loss, low fat diet, and regular exercise are also important.
If you develop sudden pain or numbness in your leg that does not get better within a few hours, contact your doctor or hospital straight away. You may be asked to go to the hospital at regular intervals after the surgery (usually 3 months before it starts) for an ultrasound scan of your bypass. This is to ensure that it is working well and that there is no narrowing of the bypass that could block the bypass.