Femoro - Femoral Bypass

What is it?
The main artery which carries blood to your bad leg is blocked near your tummy button. The leg is starved of blood. This causes pain, infection and even loss of the limb. The artery carrying blood to your other leg is not blocked. Some of the blood from the good side can be led across to the bad side (bypass the problem) using a new piece of artificial artery (vascular graft). The blood will then run down the leg arteries below the blocked part. The pain and infection then get better. Your good leg can easily spare some blood to go to the bad side. 

The Operation 
You will probably have a general anaesthetic, and will be asleep for the whole operation. Sometimes you may be numbed from the waist down with an injection in your back or groin. A cut is made into the skin in the groin and thigh on each side. The left and right arteries are found below any blockages. A new artificial artery of a special plastic material is stitched in place to join the two arteries under the skin. The cuts are then stitched up. If all goes well, you should plan to leave the hospital about five to seven days after the operation.

Any Alternatives 
Drugs and antibiotics by themselves will not work. Injections into the nerve in your back which control the arteries will not help. Unblocking the artery with an X-ray guided balloon or a laser will not work for you. An alternative to re-routing blood from the other limb is a major operation on your tummy arteries or a medium operation to channel blood from an artery just below your collar bone. For you they are not as beneficial as getting a If you do nothing, the problems you are having with your limb will surely get worse. blood supply from your other groin. The doctors are aiming to save your leg by doing the planned graft. Sometimes it is better and safer to go ahead with an amputation than a graft.

Before the operation
Stop smoking and try to get your weight down if you are overweight. (See Healthy Living). If you know that you have problems with your blood pressure, your heart, or your lungs, ask your family doctor to check that these are under control. Check the hospital's advice about taking the Pill or hormone replacement therapy (HRT). Check you have a relative or friend who can come with you to the hospital, take you home, and look after you for the first week after the operation. Sort out any tablets, medicines, inhalers that you are using. Keep them in their original boxes and packets. Bring them to the hospital with you. On the ward, you may be checked for past illnesses and may have special tests to make sure that you are well prepared and that you can have the operation as safely as possible. Please tell the doctors and nurses of any allergies to tablets, medicines or dressings. You will have the operation explained to you and will be asked to fill in an operation consent form. Many hospitals now run special preadmission clinics, where you visit for an hour or two, a few weeks or so before the operation for these checks. 

After - In Hospital 
You will have a fine, thin plastic drip tube in an arm vein connected to a plastic bag on a stand containing a salt solution or blood. You will have dressings on your wounds and possibly fine, plastic drainage tubes in the nearby skin connected to plastic containers. These are in order to drain any residual blood or other fluid from the area of the operation. You may be give oxygen from a face mask for a few hours if you have had chest problems in the past. The wounds are a bit painful and you will be given injections and later tablets to control this. Ask for more if the pain is not well controlled or if it gets worse. A general anaesthetic will make you slow, clumsy and forgetful for about 24 hours. The nurses will help you with everything you need until you are able to do things for yourself. Do not make important decisions during this time. You will most likely be able to get out of bed with the help of the nurses the day after the operation despite some discomfort. You will not do the wound any harm, and the exercise is very helpful for you. The second day after operation you should be able to spend an hour or two out of bed. By the end of 4 days you should have little pain. It is important that you pass urine and empty your bladder within 6 to 12 hours of the operation. If you cannot pass urine, let the doctors or nurses know. Each wound has a dressing which may show some staining with old blood in the first 24 hours. You can take the dressings off after 48 hours. There is no need for a dressing after this unless the wound is painful when rubbed by clothing. There may be stitches or clips in the skin. The wounds may be held together underneath the skin with stitches that eventually dissolve and they don’t need to be removed. Any plastic drainage tube is taken out after two days or so. 

There may be some purple bruising around the wound which spreads downwards by gravity and fades to a yellow colour after two to three days. This is expected and you should not worry about it. There may be some swelling of the surrounding skin which also improves in two to three days. After 7 to 10 days, slight crusts on the wound will fall off. Occasionally minor matchhead sized blebs (blisters) form on the wound line, but these settle down after discharging a blob of yellow fluid for a day or so. You can wash as soon as the dressing has been removed. Try to keep the wounds dry until the stitches/clips come out which is usually 10 to 14 days after the operation. If there only stitches under the skin, try to keep the wounds dry for a week. Soap and warm tap water are entirely adequate. Salted water is not necessary. You can shower or bath as often as you want. You will be given an appointment to visit the outpatient department for a check-up about one month after you leave the hospital. The nurses will advise about sick notes, certificates etc.

After - At Home
You are likely to feel very tired and need to rest two or three times a day for two weeks or more. You will gradually improve so that by the time two months have passed you should be able to return completely to your usual level of activity. You can drive as soon as you can make an emergency stop without discomfort in the wound, i.e. after about three weeks. You can restart sexual relations within two or three weeks when the wound is comfortable enough. You should be able to return to a light job after about six weeks and any heavy job within 12 weeks.

Once the laparoscope is in place, the surgeon will make 4 or 5 more "keyhole" incisions in the abdomen. Surgical instruments will be placed through these incisions to complete the surgery. 

Possible Complications

If you have this operation under general anaesthetic, there is a risk of complications related to your heart and lungs. The tests that you will have before the operation will make sure that you can have the operation in the safest possible way and will reduce the chances for such complications. 

If you have an anaesthetic injection in the back, there is a very small chance of a blood clot forming on top of your spine which can cause a feeling of numbness or pins and needles in your legs. The clot usually dissolves on its own and this solves the problem. Extremely rarely, the injections can cause permanent damage to your spine.

Complications are rapidly recognised and dealt with by the surgical staff. If you think that all is not well, please let the doctors and nurses know. Sometimes there is some bleeding under the wounds which causes more severe bruising. This usually settles down. However, there is a small chance of severe bleeding in the area of the operation that might require another operation to stop it. 

Sometimes the blood in the new artificial artery clots. This usually needs a second operation to clear the blockage. Sometimes the arteries further down the leg cannot take the extra flow of blood. The next steps to deal with this will be discussed with you. The worst case scenario is that the a satisfactory blood supply to the leg cannot be restored in which case you may need an amputation (removal of the diseased part of the leg). 

Wound infection is sometimes seen. This settles down with antibiotics in a week or two. It is much more serious if the infection spreads into your bloodstream or if the new artificial artery gets infected. If this is the case you will need antibiotics for much longer and it may be that the new artificial artery has to be removed to allow the infection to clear. Sometimes fluid builds up under the wounds. This settles down with time. There is a very small chance that you will experience steal syndrome in your “good”, healthy. This is a feeling of pins and needles, numbness, coldness or even pain. This happens because the new artificial artery “steals” or diverts more blood than your healthy leg can afford to give to the diseased leg(s). The upper limb needs this blood to maintain its circulation and function. The problems that you experience in your healthy leg usually get better but there is a chance that the artificial artery has to be removed to save the healthy leg and prevent further problems. 

Aches and twinges may be felt in the wound for up to six months. Occasionally there are numb patches in the skin around the wound which get better after two to three months. The overall results of this operation are very good. Close to 75% of the new artificial arteries of the femoro-femoral bypasses remain open five years after the operation and patients experience a good quality of life. 

General Advice 
The operation is routine in many hospitals but as with all operations involving the blood vessels it should not be underestimated. Your recovery depends on the state of the other arteries in the legs, but is usually relatively quick and good. You should never smoke after the operation because this causes the new artery to close up. These notes should help you through your operation. They are a general guide. They do not cover everything. Also, all hospitals and surgeons vary a little. If you have any queries or problems, please ask the doctors or nurses

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