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Date issued: December 2023

Review date: December 2025

Ref: A-605/JW/vascular/Femoropopliteal and Femorodistal Bypass The Operation Explained

PDF: Femoropopliteal and Femorodistal Bypass the operation explained.pdf[pdf] 245KB

Why do I need the operation?

There is a blockage of the artery supplying your leg, and the circulation of blood to your leg is reduced. The operation is to bypass the blocked artery in the leg so that the blood supply is improved.

Before your operation

Before bypass surgery, there are a number of tests that need to be done. These are of two types:

1. Tests of fitness and suitability are normally done before a decision to operate is made. They normally include blood tests, ECG (electrical tracing of the heart), an ultrasound scan of the blocked artery and an X-ray of the arteries (arteriogram). Usually a leg vein is used to bypass the blockage; this will be assessed using ultrasound before the operation and may be marked with an indelible pen.

2. Immediate pre-operative tests include: blood tests, another ECG and completing the paperwork. These tests are usually completed at a pre-admission visit to the hospital a few days before your operation. Occasionally, they are done when you are admitted to hospital for the operation.

Coming into hospital 

Please bring with you all the medications that you are currently taking. You will be admitted to your bed by one of the nurses who will also complete your nursing record.

You will be visited by the Surgeon who will be performing your operation and also by the doctor who will give you the anaesthetic. Your operation, in exceptional circumstances, may be performed by a Vascular Consultant who did not assess you in clinic.

Physiotherapists and Intensive Care staff may also visit to give you information about your post-operative care. If you have any questions regarding the operation, please do not hesitate to ask the Doctors.

The Anaesthetic

The first part of the operation involves giving you an anaesthetic. The operation can be done with you asleep, or awake:

• If you go to sleep, a tiny needle is placed in the back of your hand. The anaesthetic is injected through the needle and you will be asleep within a few seconds.

• If you are to be awake, you will have a small tube placed in your back. This may be a spinal or an epidural anaesthetic

A spinal anaesthetic stops you from feeling anything from waist downward on the operation side. The leg is paralysed. This anaesthetic lasts for about 2-2½ hours.

An epidural again stops you from feeling anything from waist downwards and affects both legs. There is no paralysis however. The epidural is like a drip and can stay in for several days to provide post-operative pain relief.

A tube (catheter) may be inserted into your bladder to drain your urine if you have a general anaesthetic. The catheter is essential if you have either the spinal or epidural anaesthesia.

For all three options, a drip is placed into a vein in your forearm to give you some fluids during and following surgery.

The Operation: e.g. Above-knee femoro-popliteal bypass

Normally, a cut about 10cm (4inches) long is made in the groin to expose the main artery (femoral artery) supplying the leg.

A second cut of similar length is made to expose the artery below the blockage. This may be just above or below the knee and is on the inner side of the leg. Occasionally, the cut is lower in the calf and may then be on either side.

The tube used to bypass the blockage will normally be your leg vein. If the vein is unsuitable, its counterpart in the other leg or a vein from the arm may be used instead. The pre-operative ultrasound assessment of the veins will determine which vein is best. If no vein is suitable, an artificial (synthetic) tube is used.

The bypass tube is joined to the artery above the blockage and again to the artery below with very fine permanent stitches.

At the end of the operation, the wounds are all closed either with dissolving stitches, which do not need to be removed, or with a non-dissolving stitch or metal clips which will normally be removed after about ten days.

After the operation

After your operation, you will be given fluids by a drip in one of your veins until you are well enough to sit up and take fluids and food by mouth.

The nurses and doctors will try and keep you free of pain by giving pain killers by injection, via the epidural tube in your back, or by a machine that you are able to control yourself by pressing a button (Patient Controlled Analgesia PCA).

Within a day or so, the drip, epidural and bladder catheter will be removed.

You will gradually become more mobile until you are fit enough to go home.

You may be visited by the physiotherapists after your operation. They will help you with your breathing to prevent you developing a chest infection and with your mobilisation to get you walking again.

Going home

If your stitches or clips are of the type that need removing, this can be done whilst you are still in hospital. If not, we will arrange for your GP’s practice or district nurse to remove them and check your wound.

You may feel tired for some weeks after the operation but this should gradually improve as time goes by.

Regular exercise such as a short walk combined with rest is recommended for the first few weeks following surgery followed by a gradual return to your normal activity.

Driving : You will be deemed safe to drive when you are able to perform an emergency stop. This will normally be 2-4 weeks after surgery but, if in doubt, check with your own doctor.

Bathing: Once your wound is dry you may bathe or shower as normal.

Work : You should be able to return to work within 6-12 weeks of surgery. We will provide you with a sick note but if you need longer off work, please see your GP.

Medicines : You will usually be sent home on a small dose of aspirin if you were not already taking it. This is to make the blood less sticky. If you are unable to tolerate aspirin, an alternative drug may be prescribed.

Complications

• Chest infections : These can occur following this type of surgery, particularly in smokers, and may require treatment with antibiotics and physiotherapy.

• Wound infection : Wounds sometimes become infected and this may need treatment with antibiotics. Bad infections are rare. Occasionally, the wound may need to be cleaned out under anaesthetic.

• Graft infection: Very rarely, the artificial graft may become infected. This is a serious complication and usually treatment involves removal of the graft.

• Fluid leak from wound: Occasionally the wound may leak fluid. This may be clear but is usually blood stained. It normally settles in time and does not usually indicate a problem with the bypass itself.

• Bowel problems: Occasionally, the bowel is slow to start working again after the operation. This requires patience and fluids will be provided in a drip until your bowels get back to normal.

• Major Complications: As with any major operation, there is a small risk of you having a medical complication such as a heart attack, stroke, kidney failure, chest problems, loss of circulation in the legs or bowel or infection in the artificial artery. Each of these is rare but, overall, it does mean that some patients may have a fatal complication from their operation. For most patients this risk is about 5% - in other words 95 in every 100 patients will make a full recovery from the operation. The doctors and nurses will try to prevent these complications and to deal with them rapidly if they occur.

• Bypass blockage: The main specific complication of this operation is blood clotting within the bypass causing it to block. If this occurs, it will usually be necessary to perform another operation to clear the bypass.

• Limb loss: Very occasionally when the bypass blocks, and the circulation cannot be restored, the circulation of the foot is so badly affected that amputation is required.

• Limb swelling: It is normal for the leg to swell after this operation. The swelling usually lasts for about 2-3 months. It normally goes away completely but may occasionally persist indefinitely.

• Skin sensation: You may have patches of numbness around the wound or lower down the leg which is due to the inevitable cutting of small nerves to the skin. This can be permanent but usually gets better within a few months.

What can I do to help myself?

If you were previously a smoker, you must make a sincere and determined effort to stop completely. Continued smoking will cause further damage to your arteries and your bypass is more likely to stop working.  It is also likely to jeopardise the success of any surgical operation carried out and to make recovery more difficult.

Why not take this opportunity to consult your own doctor or the practice nursing staff to seek professional help in giving up the addiction?

Further help is available locally from the Smoking Advice Service, Tel: 0300 123 1044, NHS Stop Smoking

General health measures such as reducing weight, a low fat diet and regular exercise are also important. If you develop sudden pain or numbness in the leg which does not get better within a few hours, then contact your GP or the hospital immediately.

You may be asked to attend the hospital at intervals after the operation to have an ultrasound scan of your bypass. This is to ensure that it is working well, and that there is no narrowing of the bypass, which might lead to a blockage of the graft.

Contact details

Vascular Surgical Unit

Surgical Directorate

Plymouth Hospitals NHS Trust

Derriford Hospital

PL6 8DH

Tel 01752 202082

Consultant Vascular Surgeon and Lead Clinician

Mr Devender Mittapalli

Secretary: 01752 431822

Consultant Vascular and Transplant Surgeon

Mr Jamie Barwell

Secretary: 01752 431822

Consultant Vascular Surgeon

Surgeon Commander Cris Parry RN

Secretary: 01752 431822

Consultant Vascular Surgeon

Miss Catherine Western

Secretary: 01752 431805

Consultant Vascular Surgeon

Lt Col Robert Faulconer

Secretary: 01752 431805

Consultant Vascular Surgeon

Mr Hashem Barakat

Secretary: 01752 431822

Vascular Scientists

• Mrs J George
• Mr A Ellison
• Mr R Craven

01752 439228

Vascular Nurse Specialist

Mr Alan Elstone

01752 431805

Matron

Judy Frame

01752 431847