Ilio-Fermoral or Femoro-Popliteal Bypass
by Dr Panayiotopoulos, Consultant Vascular and General Surgeon Essex.

A. Ilio-Fermoral or Femoro-Femoral Bypass

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.

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 iliofemoral/femorofemoral 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 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.

a. Iliofemoral bypass.

You will usually have a cut down across your flank [abdomen] and also a smaller cut in the groin.

An artificial blood vessel [synthetic graft] made of plastic [polyester] will be inserted into the back of your abdomen and will be joined to the main blood vessel [iliac] that conveys all the blood to the artery in your groin and the artery in the groin of the affected leg [femoral artery], bypassing thus the blocked arteries [iliofemoral graft].

Depending on the extent of the blockage, the artery of the same or the opposite site may be used as a donor site.

This a major and lengthy procedure, during which you will be given drugs to thin your blood and blood transfusions.

The wounds are usually closed with dissolvable stitches, buried underneath the skin.

b. Femoro-femoral bypass.

If there are particular problems with your chest and heart, your surgeon may decide to avoid a cut in your abdomen, which is a far more major procedure with much more demands on your physiological reserves, and bring blood to your legs from the opposite femoral artery. In this case you will have a two cuts in your groins. An artificial blood vessel will be tunneled under your skin between these incisions and will be attached to the main vessel supplying each leg. Once again the wounds will be closed by dissolvable stitches.

The femoro-femoral bypass may not last as long as an ilio-femoral, 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.

Following this sort of surgery [with a cut in your abdomen] your bowel may stop working for a while and 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. One of the first signs that your bowel is working is when you pass wind down below.

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.

n    Occasionally the bowel is slow to start working again, but this requires patience and fluids will be provided in a drip until your bowel gets back to normal.

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 will feel tired for some weeks following the operation but this should gradually improve [after the 4^th 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 wound 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.

Ilio-femoral grafts remain open in 70-80% of the patients for 5 years.

Femoro-femoral grafts have a slightly worse outcome with 60-70% remaining open at the end of 5 years.

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.

B. Fermoral-opliteal or Femorodistal Leg Bypass

1. Why do I need the operation?

Because you have a blockage or narrowing of the arteries supplying your legs, the circulation of blood in your legs is reduced. This becomes particularly noticeable when your muscles require more blood during walking and causes pain. Any further fall in the flow of blood may lead to constant pain with the risks of developing ulcers or gangrene.

2. Before your operation.

If you are not already in the hospital you will be admitted one or two days before the operation or you will be asked to attend a pre-admission clinic about a week before the operation in order to allow time for tests required to make sure you are fit for the operation. An x-ray of the arteries [arteriogram] to find where the blockages are may be performed if it has not already been done.

3. 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 note down your personal details in your nursing records. 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. The surgical team who will perform your operation will visit you, as well as the doctor who will give you the anaesthetic. If you have any questions regarding the operation please ask the doctors. You will be started on injections of heparin, which will continue throughout your stay in hospital. This stops blood clots forming in the veins of your legs.

4. The operation.

You will be taken into the anaesthetic room and from there to theatres. You will either be put to sleep [a general anaesthetic] or you will have a small tube placed in your back [epidural] which can make numb the lower part of your body and helps with pain relief following surgery, by injecting pain killers through it. Sometimes you will have this as well as general anaesthetic in order to provide pain relief after surgery. Whilst you are asleep, tubes will also be inserted into your bladder to drain your urine and into a vein in your arm or neck or both for blood pressure measurements and administration of fluids following surgery.

The wounds are often closed by a stitch under the skin that dissolves by itself; sometimes metal staples may be preferred.

5. After the operation.

After the operation you will be given all the fluids you require in a drip in one of your veins until you are well enough to sit up and take fluids and food by mouth. Most patients sit out in a chair on the first day after surgery and you will be encouraged to walk the second day.

As the days pass and you improve the various tubes will be removed and you will become gradually more mobile until you are fit enough to go home. This is usually 7-14 days after your operation. The physiotherapist will visit you before and after the operation, to help you with your walking and with your breathing, in order to prevent you developing a chest infection.

6. Going home.

n   As dissolvable stitches have been used, these do not need to be removed. However, the stitch takes a long time to dissolve and if it comes to the surface it may be removed with a tweezers.

n   You will feel tired for many weeks after the operation but this should gradually improve 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.

n   Driving: You will be safe to drive when you are able to move without pain and perform an emergency car stop.

n   Bathing: You may bathe or shower as normal, but do not soak in a bath until the wound is fully healed [i.e. no scabs as these may become soggy]

n   Work: You should be able to return to work within 1-3 months following your operation. If in doubt, please ask your doctor.

n   Medications: 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. You should also continue taking your regular medications.

n   Sexual activity: You may resume sexual activity when you feel comfortable to do so.

7. Complications.

n   The main complication with this sort of surgery is blood clotting within the graft causing it to block, and if this occurs it will usually be necessary to perform another operation or a special x-ray procedure [thrombolysis] to clear the graft. If your leg is in danger because of its poor blood supply prior to surgery, there is a risk of you ending up with an amputation if the graft blocks.

n   Wound problems: Slight discomfort and twinges of pain in your wound is normal for several weeks following surgery, but wounds sometimes become infected and these can usually be successfully treated with antibiotics. Also the wound in your groin may fill with a fluid called lymph that may discharge between the stitches, but this usually settles down with time. If you had a long cut down your leg to harvest your leg vein, this wound may be red and swollen for 7-14 days and some fluid may ooze from it.

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

n   It is also common for the foot to swell due to improved blood supply. You must sit with your leg higher than your bottom until the swelling goes.

8. What is the success rate?

After 5 years 70-80% of the above knee femoropopliteal bypasses remain open. Regarding below knee grafts 60-70% remain open, while for femorodistal grafts 30-50% are still open after 5 years.

The results are better in the long-term if your leg vein had been used as conduit.

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?

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 graft is more likely to stop working.

General health measures such as reducing weight, a low fat diet and regular exercise are also important.

·      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.