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Patient
Advice and Information
Axillo-Fermoral
Bypass
by Dr Panayiotopoulos, Consultant Vascular and General Surgeon
Essex.
1. Why do I need the operation?
Because of a blockage or significant narrowing of the big
arteries into the stomach [abdomen] supplying the legs with
blood, the circulation to your legs is reduced. This becomes
particularly noticeable when your muscles require more blood during
walking or exercise; as they are deprived from oxygen [transferred
by blood] pain appears, affecting the thigh, the buttocks
and/or the calves, forcing you to stop for some minutes. Men may
also have sexual dysfunction and problems with erection.
Any further
fall in blood flow because of disease progression may lead to
constant pain even at rest with a significant risk of developing
ulcers or gangrene.
In order to improve blood supply
to your legs, an operation is needed to bypass the blocked
arteries in your abdomen.
2. What causes this blockage?
Atherosclerosis!!!
This is a progressive disease that causes gradual narrowing and
hardening of the arteries, which is both caused and accelerated by
smoking, high blood pressure, high cholesterol levels in the
blood, fatty diet and sedentary life. It may affect any vessel
in body but its distribution is usually multifocal. When it affects
the aorta and the main arteries in the abdomen it is called
aortoiliac occlusive arterial disease. This condition is more
common in the lower extremities of middle-aged and elderly patients
in the western world.
3. Before
your operation.
You will be admitted in the
hospital one or two days before the operation. You may also be asked
to attend a pre-admission clinic about a week earlier in order to
allow time for tests and required to ensure you are fit for
the operation, as the aortofemoral bypass is a major procedure.
These tests may include
scans of the abdomen or x-rays of the arteries [angiography,
arteriogram] if these have not been done during your previous
visits to the hospital. Special scans of your heart to check that it
is working properly and evaluation by an anaesthetist may also be
needed.
4. Coming
into Hospital.
Please bring with you all the
medicines you are taking to show to the doctor.
You will be received in the
ward by a nurse, who will note your personal details in the
nursing records and will ask about any other conditions you suffer
from. Prior to surgery you will undergo a number of
investigations, if these have not been performed previously,
including a heart tracing, a chest x-ray and blood tests. You will
be started on injections to thin your blood [heparin], which will
continue through out your stay in the hospital, to stop blood clots
forming in the veins of your legs while you lie on the bed.
You will be also visited by
members of the surgical team and the anaesthetist. The
surgeon who will perform the operation will see you the
morning of surgery. If you have any questions regarding the
operation please ask the doctors.
5. The
operation.
You will be taken to the
anaesthetic room and from there into the theatre. As well
as being put to sleep, you may have a small tube placed in your
back [epidural] to help pain relief following surgery. Whilst
you are asleep, tubes will be also inserted into your bladder
to drain the urine, into your stomach [via your nose] to stop
you feeling sick and vomit and into a vein in your neck for
blood pressure measurements and administration of fluid during and
after surgery.
Axillo-femoral bypass.
An axillofemoral or bifemoral
bypass is used because there are particular problems with your chest
and heart. Thus, you avoid a cut in your abdomen, which is a far
more major procedure with much more demands on your physiological
reserves. Blood is brought to your legs from the axillary artery.
In this case
you will have a cut below one if your collar bones, usually
the right, a vertical cut in each groin and a small cut in your
loin. An artificial blood vessel shaped like an upside down Y
will be tunneled under your skin between these incisions and
will be attached to the main vessel supplying one arm and to the
main blood vessel supplying each leg. Your arm can easily spare the
blood required by your legs through this bypass.
This a major and procedure, during which you will be
given drugs to thin your blood. Usually no major blood transfusion
is needed.
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Axillo-bi-femoral bypass
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Not
such major procedure
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Can be
used in patients that are not that fit for surgery
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Often
as a redo procedure following previous aortic surgery
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The
results are good, but not as good as those of aortofemoral
bypass
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The wounds are usually closed with dissolvable
stitches, buried underneath the skin.
The axillofemoral bypass may not
last as long as an aortofemoral, but this disadvantage should be
balanced with the far less risk of surgery, as it is not such
a major procedure.
6. After
the operation.
There is usually no need to be
taken to an intensive care or high dependency unit following
your operation.
You will be given all the
fluids you require in a drip, until your bowel will be able to
cope with fluids given by mouth.
The nurses and doctors will try to
keep you free of pain by giving pain killers by injection,
via a tube in your back [epidural] or by a machine that you are able
to control yourself by pressing a button. As days pass and you
improve the various tubes will be removed and you will be returned
to the normal ward until you are fit to go home.
You will be visited by the
physiotherapist before and after the operation who will help you
with your breathing, to prevent you developing a chest infection and
with your walking.
7.
Complications.
n
Chest infections
may occur following this type of surgery, particularly in
smokers, and may require treatment with antibiotics and
physiotherapy.
n
Slight discomfort and twinges of
pain in your wound is normal for several weeks following
surgery, but wounds sometimes become infected [2%] and these
can be usually treated with antibiotics. Also the wound in your
groin can fill with a watery fluid called lymph that may
discharge between the stitches, but this usually settles down with
time.
n
As with any major operation such as this, there is a
very small risk of you having a medical complication such as
a heart attack, but the doctors and nurses will try to
prevent these complications and to deal with them rapidly if they
occur.
8. Going
home.
As dissolvable stitches had
been used, these do not need to be removed; they will be cut flash
to the skin on day three. However, the buried stitch takes long time
to dissolve and if it comes to the surface it may be removed with a
tweezers.
You may feel tired for some
weeks following the operation
but this should gradually improve [after the 4th week] as
time goes by. Regular exercise such as short walk combined with
periods of rest is recommended for the first few weeks after
surgery, followed by a gradual return to your normal activity.
Driving:
You will be safe to drive when you are able to move without pain and
you are able to perform an emergency stop.
Bathing:
You may bathe or shower as normal, but do not soak in bath until the
wouind is fully healed [i.e. no scabs as these can become soggy].
Work: You should be able to return
to work within 1-3 months following your operation. If in doubt,
please ask your doctor.
Lifting:
You should avoid heavy lifting or straining for the first 4 weeks
after the operation in order to reduce the risk of incisional hernia
in your abdominal wound.
Medication:
You will continue your regular medication. From the vascular point
of view, the only necessary drug is a small dose of aspirin, if you
were not already taking it. This is to make your blood less sticky.
If you are unable to tolerate aspirin, an alternative drug may be
used. For axillofemoral bypass there is usually a need to put you in
long term anticoagulation with warfarin to thin your blood and avoid
graft clotting. In such a condition you should have a regular blood
test every 1-3 months to check the drug effect and correct the dose.
9.
Follow-up?
Your vascular Surgeon will see you in the outpatients
clinic 6 weeks after discharge. As these types of grafts do not last
for ever, you will be entered into a surveillance program and
a painless ultrasound scan of the graft will be performed after 3
months, then 6 months and after this at 6 or 12 monthly intervals.
Thus we can detect early narrowings of the graft and proceed to
angioplasty [ballooning of the narrowing in x-ray department] if
there is a need to do so, extending thus graft survival.
10. What
can I do to help myself?
Arterial bypass is dealing with
the present problem of arterial blockage and does not confront the
actual disease which is atherosclerosis. Therefore you should try
and control all the risk factors that make the disease more
aggressive.
If you were previously a smoker,
you must make a sincere effort to stop smoking completely.
Continued smoking will cause further damage to your arteries and
your graft is more likely to stop working.
Low fat diet
and other general health measures such as reducing weight and
regular exercise are also important.
If your cholesterol levels are
high and cannot be controlled by diet, you may have to be put on
a drug to bring blood lipids down to normal levels.
Control of hypertension
is essential.
11. What
is the fate of the bypass graft?
All grafts do sometimes fail, but
the overall result is good if you take good care of yourself
and control the risk factors.
Axillofemoral grafts remain
open at the end of 5 years in 60-75%.
If your graft blocks, the
symptoms you had previously will recur;
if this happens, then you should come promptly to the hospital,
as 25% of grafts can be reopened by surgery performed under local
anaesthesia, provided that you come to the hospital early.
· IF YOU DEVELOP ANY
SEVERE PAIN IN THE LEG THE GRAFT MAY BE BLOCKED; THE SOONER YOU GET
BACK TO THE HOSPITAL THE EASIER IT IS FOR IT TO BE UNBLOCKED.
·
Please ring the Ward on
01245-514233 or
·
The vascular lab on
01245-514145 or
·
The Consultant’s
secretary on 01245-514095
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Please note:
A written referral from a general practitioner is helpful but is not essentially required in order to make an appointment to see a consultant specialist. |
