Femoro-Popliteal Bypass :
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What is peripheral arterial disease?
Peripheral arterial disease (PAD) is generally associated with blocked arteries of the legs. The blockage most often is the result of a chronic buildup of hard fatty material (atherosclerosis or hardening of the arteries) into the inside lining of the arterial wall of the legs.
This ultimately narrows and blocks the flow of blood which carries oxygen and nutrients to the limb. The femoral and popliteal arteries are the major arterial blood supply to the lower extremities and are a common location for atherosclerotic disease to develop.
The presence of atherosclerosis in the leg arteries is a strong indicator that there is also atherosclerosis in the arteries of the heart and brain, because atherosclerosis is a widespread disease of the arteries.
Atherosclerosis of the leg arteries may cause a blockage, obstructing blood flow, and potentially result in pain in the leg(s), ulcers or wounds that do not heal, and/or the need for amputation (surgical removal) of a foot or leg.
Therefore, PAD has two major complications associated with its presence: limb complications (nonhealing wounds, ulcers, gangrene, loss of a limb) and risk for stroke and/or heart attack.
Peripheral arterial disease caused by atherosclerosis may be present with symptoms or without symptoms. The presence of symptoms may depend on the degree to which blood flow to the leg muscles has been decreased. Symptoms may range from mild to moderate to severe.
- Caregivers make 2 to 3 incisions (cuts) in your leg. One is along your inner thigh and the other is along the inside of your knee. An incision may be made in your lower leg so a vein can be removed for a graft. The vein from your lower leg or a man-made graft (tube) is sewed to your femoral artery above the blocked area. It is then tunneled under the skin and muscles in your thigh to the incision near your knee. The far end of the graft is sewed to the popliteal artery below the blocked area. Blood then flows through the vein or graft around the blocked area.
- The incisions is closed with stitches or staples. Steri-strips (thin strips of tape) may be put over your incisions. Bandages are put on your incisions and elastic bandages are wrapped around your leg.
You will be given:
- Catheters to monitor the blood pressure in your veins and arteries, as well as your urinary output
In most cases, general anesthesia by injection and inhalation is given. In some cases, spinal anesthesia by injection is given.
Description of the Procedure
The surgeon makes an incision in the thigh along the portion of the saphenous vein to be removed for use as the bypass graft. (The saphenous vein runs the full length of the thigh.) The vein is dissected and removed. (If the vein is unsuitable to be used as a graft, an artificial, tubular prosthetic graft is used instead.) Once the vein is removed, the small branches of the vein are tied off.
Next, an incision is made in the groin to expose the femoral artery. Another incision is made near the inside of the back of the knee to expose the popliteal artery.
The femoral artery and the popliteal artery are then isolated and clamped (with vascular clamps) to block the flow of blood while the graft is being attached. The piece of the saphenous vein that is now the graft is tunneled along the femoral artery from the groin to the knee. One end of this vein graft is stitched into the femoral artery at the groin, and the other end of the vein graft is stitched into the popliteal artery at the knee. (Because the vein has small valves inside of it that prevent the back flow of blood, the saphenous vein must be reversed before being tunneled and attached to the arteries.)
Once the graft is attached, blood is passed through the vein graft to check for any leaks, which, if found, are repaired. The vascular clamps are then removed, allowing blood to flow through the graft to the lower leg. The incisions are closed with stitches.
In some cases, rather than being removed, reversed, and tunneled, the saphenous vein is used as a graft while left in place. This is called in situ. In this procedure, the valves inside the vein are removed with a small scope and a small cutting instrument known as a valvulotome. The vein is then, while still in situ, attached to the femoral and popliteal arteries to form a graft.
After obtaining a detailed history and reviewing symptoms, the physician examines the legs and feet, and orders appropriate tests or procedures to evaluate the vascular system. Diagnostic tests and procedures may include:
Blood pressure and pulses—pressure measurements are taken in the arms and legs. Pulses are measured in the arms, armpits, wrists, groin, ankles, and behind the knees to determine where blockages may exist, since no pulse is usually felt below a blockage.
Doppler ultrasonography—direct measurement of blood flow and rates of flow, sometimes performed in conjunction with stress testing (tests that incorporate an exercise component).
Angiography—an x ray procedure that provides clear images of the affected arteries before surgery is performed.
Blood tests—routine tests such as cholesterol and glucose, as well as tests to help identify other causes of narrowed arteries, such as inflammation, thoracic outlet syndrome, high homocycteine levels, or arteritis.
Spiral computed tomography (CT angiography) or magnetic resonance angiography (MRA)—less invasive forms of angiography.
All surgeries carry risks. There is a risk of infection whenever an incision is required. Other risks include:
The risk of death because of fem-pop bypass surgery is from 1% to 3%.
- Failed or blocked grafts.
- Heart attack or stroke.
- Leg swelling.
Reasons for Procedure
- To restore proper blood supply to the lower leg
- To relieve leg pain caused by a blocked artery
- To prevent amputation of the lower leg due to insufficient blood supply
Patients having bypass procedures in the leg are liable to develop the usual complications which apply to all forms of surgery such as wound infection and chest infection. Because it is usually an older age group requiring this operation there is an increased risk of heart problems after surgery. Particular problems from the bypass operation itself include bleeding from the openings in the blood vessels or sudden blockage of the bypass. If the bypass stops suddenly it will usually be necessary to re-operate immediately. When the surgery is being performed to save the leg, there is a risk that amputation will be required if surgery is unsuccessful.
The most severe symptom of peripheral arterial disease caused by atherosclerosis is called critical limb ischemia (lack of oxygen to the limb/leg at rest). Critical limb ischemia (CLI) is defined as pain in the leg(s) while at rest, or "rest pain."
- Cool/cold feet to touch
- Pain in the legs while lying flat and relieved by a sitting position
- Loss of pulses in legs or feet
- Pale color when legs are raised up
- Dependent rubor (redness when legs are in a dependent [hanging down] position)
- Shiny skin
- Loss of hair on feet
- Thickened toenail (may have fungal infections)
- Nonhealing wound or ulcer
- Loss of muscle or fatty tissue
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