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Peripheral Artery Bypass Surgery

What is peripheral artery bypass surgery?

Peripheral artery bypass surgery is a procedure to treat PAD and restore blood flow to the legs by redirecting blood around the blocked or narrowed artery.

Peripheral artery bypass surgery is similar to coronary artery bypass surgery (CABG), a treatment for disease in the arteries that supply blood to the heart. During the surgery, a healthy vein from another part of your body (usually the saphenous vein that runs from your thigh to your ankle) is used to re-route blood around the diseased artery. Sometimes a synthetic artery substitute is used instead. The replacement vessel is called a bypass graft. One end of the bypass graft is attached to the artery above the blockage and the other end is attached below, allowing blood to flow smoothly.

Peripheral artery bypass surgery can relieve symptoms of PAD in the legs and improve walking ability. In women with severe PAD that is causing damage to the leg tissues because of lack of blood flow, bypass surgery can save the leg and prevent amputation.

Who might have peripheral artery bypass surgery?

For many women, lifestyle changes, medications and exercise therapy are enough to get PAD symptoms under control. However, women with severe PAD that has not responded to other treatments may need a procedure to open the blocked artery. You may benefit from peripheral artery bypass surgery if you have PAD in the legs and:

  • Your PAD symptoms are limiting your ability to work or perform daily tasks
  • Medication and exercise therapy have failed to control your symptoms
  • A narrowing or blockage in your leg arteries is limiting blood flow to your legs
  • You are not eligible for angioplasty or stenting to treat PAD because of the size or location of your artery blockages, or you have already had one of these procedures and your symptoms have not improved
  • Surgery to treat PAD has a high chance of success and a low risk of complications (such as heart attack and stroke) during and after the procedure

Women with severe PAD that is damaging leg tissues because the legs are not receiving enough oxygen (critical limb ischemia) may also benefit from peripheral artery bypass surgery to restore blood flow to the legs and prevent amputation.

Who should not have the procedure?

You should not have a surgical procedure for leg pain symptoms until you have tried the other available treatments, including (if you are eligible) angioplasty and stents. The surgery should not be performed to prevent future blood flow problems, only to improve symptoms.1

Most women younger than 50 should not have bypass surgery to treat symptoms caused by PAD in the legs.1 This is because women who develop the disease at a younger age often have a more aggressive form of artery disease that makes the procedure less likely to be successful. Younger women also have a higher risk of complications during the surgery, and are more likely to need additional procedures to treat PAD or open a bypass graft that has become re-blocked.2,3

How do doctors decide which procedure is best for me?

If other treatments have failed to control your PAD symptoms, your main options are angioplasty and stenting and peripheral artery bypass surgery. Which procedure is best for you depends on the location and size of your blockages and your general health. Before you have a procedure, tests such as ultrasound, MR angiography, CT angiography, or a contrast angiogram will be performed to examine your artery blockages and decide on the best treatment.

Bypass surgery was once the standard procedure to treat PAD, but today angioplasty is much more common.4 Angioplasty and stenting are the first choice for most women because they are as effective as surgery for many blockages, and have fewer risks and a shorter recovery time.1

However, surgery may still be the preferred treatment in certain cases. Some blockages are too long or in a difficult location to treat with angioplasty and stenting. Surgery may also be required if you already had an angioplasty or stent procedure that failed to restore blood flow and improve your PAD symptoms. Peripheral artery bypass surgery may be necessary if you have severe PAD that is causing tissue in your legs to die (critical limb ischemia), risking amputation if blood flow is not restored.

What are the benefits of peripheral artery bypass surgery in women with PAD?

If the procedure is successful, bypass surgery reduces or eliminates the symptoms of PAD in most patients, improving walking ability and quality of life.1 However, it does not cure PAD, and you may need additional treatments in the future to re-open the bypass graft or treat other arteries that have become blocked.

Success rates of bypass surgery to treat PAD depend on the location and severity of your disease and the type of replacement vessel used to create the bypass graft. Surgery to treat artery disease in the lower abdomen or upper legs has 5-year success rates of 80% to 90%,5,6 compared with 50% to 70% for blockages lower in the legs.7,8 The bypass graft is more likely to become re-blocked if doctors used an artificial graft instead of vein taken from elsewhere in your body. An artificial graft may be necessary if your leg veins are not long enough or healthy enough to be used.

How do I prepare for the procedure?

Be sure your doctor knows about all medications you are taking, including prescription medication, over-the counter drugs, and any dietary or herbal supplements. Some medications, such as the blood thing drugs warfarin (Coumadin), clopidogrel (Plavix), and aspirin can increase your risk of bleeding, and you may be instructed to stop taking them a few days before the procedure.

Women with diabetes should ask their doctor how to maintain blood sugar control before and after the procedure. If you smoke, get the help you need to quit smoking before the surgery. Quitting smoking will reduce your risk of complications, help you recover faster, and protect your long-term health.

Before the procedure, you will have standard tests including blood and urine tests, an electrocardiogram (ECG), and a chest-X-ray. These may be done a few days before the procedure or after you are admitted to the hospital.

You should not eat or drink after midnight the night before surgery. Your doctor may give you other special instructions.

What happens during the procedure?

Peripheral artery bypass surgery takes place in an operating room at the hospital. You will be placed on a stretcher and the nurse will insert an intravenous (IV) line into a vein in your arm so that medications can be given during the procedure.

Most bypass procedures involve general anesthesia, so you will not be conscious. For some procedures, especially those in the lower legs, you will remain conscious and have an injection in the spine (epidural anesthesia) that blocks pain in your lower body. You will be given a mild sedative to help you relax.

If doctors are using one of your own veins to create the bypass graft, the first step is to remove this vein. The most commonly used vein is the saphenous vein, which runs from your thigh to your ankle. An incision will be made in the thigh and a section of the vein will be removed. Removing this vein is harmless because other nearby veins will take over for its blood flow. If your saphenous vein is not healthy or long enough, or if a larger bypass graft is needed, an artificial vein graft may be used instead.

To perform the procedure, an incision is made in your abdomen or leg to access the blocked artery. Metal clamps will be used to block blood flow through the artery. The surgeon will make an incision in the artery above the blockage and sew one end of the vein graft into place. The other end of the graft will be attached below the blockage, creating a path for blood to flow freely around the blocked artery. When the graft is in place, the clamps will be removed and the incision will be closed up.

Your doctor may then perform an imaging test, such as an ultrasound or angiogram, to make sure blood is flowing properly.

The procedure can take anywhere from 1 to 6 hours, depending on the location and complexity of your surgery. Bypass surgery that involves opening the abdomen and attaching a graft to the aorta (the large artery that runs from the heart down through your abdomen) is more complicated and takes longer than surgery involving only a leg incision. Your surgeon will be able to give you an estimate of how long your procedure is expected to take.

What happens after the procedure?

You will be transferred to a recovery area after the procedure. As you recover from the anesthesia, the incision sites will be checked for bleeding, swelling, or inflammation and your vital signs will be continuously monitored.

From the recovery room, you will be moved to the intensive care unit (ICU) or a regular hospital room, where your family can visit you briefly. If you had surgery to treat a blockage in your legs, you will be out of bed a few hours after the surgery, and will stay in the hospital from two to four days. If you had surgery to treat arteries in your abdomen, you will stay in bed for 24 to 48 hours after the procedure, and will need to remain in the hospital for up to a week.

Nurses will regularly check the pulses in your leg to make sure blood is flowing well. Let them know if you feel numbness or coolness, or notice pale skin in the leg that was treated, or if you experience any other new symptoms. You may be given pain medication to make you more comfortable, so speak up if you still have pain.

Some swelling after the surgery is normal. You should expect to start walking soon after surgery, which reduces swelling, maintains blood flow, and helps your incision heal. Talk to your doctor about how much activity is safe for you after the surgery: you will be encouraged to gradually increase your activity level to keep blood flowing and maintain muscle strength. Most women who have a procedure to treat PAD should participate in an exercise rehabilitation program to build muscle strength and maximize their walking ability.

You will be given instructions on how to manage your incisions and medication (such as aspirin) to prevent blood clots. Check your incision every day for signs of infection such as warmth, swelling, bleeding, or drainage. Contact your doctor immediately if you develop a fever, dizziness or faintness, or feel chest pain or shortness of breath. You should not drive for a week after the surgery, or while you are still taking pain medication. Try to avoid sitting or standing with your feet down for long periods, and raise your feet up on a stool or chair when you sit down. The doctor or nurse may give you other special instructions.

You will need to return to the hospital a few weeks later for removal of the stitches or staples that closed your incision. For up to two years after your procedure, you will need to undergo regular examinations to evaluate your PAD symptoms and see how well blood is flowing to your legs (including an ankle-brachial index test). Your doctor may also want to perform a duplex ultrasound test to make sure the bypass graft has not become blocked.

What are the risks of peripheral artery bypass surgery?

As with all surgical procedures, peripheral artery bypass surgery involves some risk. Because it is often performed in women with severe PAD and other health problems, between 1% and 6% of patients die during the surgery. Death during the procedure is often due to blood clots that cause a heart attack or stroke.1

A few small studies have found that women are more likely than men to die in the hospital after peripheral artery bypass surgery (7% of women compared with 4% of men)9, but there were too few women in the studies to be sure this was not due to chance.10 Bypass grafts are twice as likely to become re-blocked in women than men, probably due to women's smaller arteries. If the bypass graft becomes blocked, another procedure is often required to restore blood flow.10

Other risks of the procedure include:

  • Blood clots that can cause a heart attack, stroke, DVT, or pulmonary embolism
  • Infection at the incision site
  • Excessive bleeding during or after the surgery
  • Nerve damage that causes pain or numbness in your legs

Making healthy lifestyle changes and following your PAD treatment plan will reduce your chances of complications after bypass surgery and make you less likely to need another procedure in the future. See Living with PAD for tips on how to stay healthy and prevent future problems after a procedure to treat PAD.

References

  1. Hirsch AT, Haskal ZJ, Hertzer NR, et al. ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation. Circulation. Mar 21 2006;113(11):e463-654.
  2. Reed AB, Conte MS, Donaldson MC, Mannick JA, Whittemore AD, Belkin M. The impact of patient age and aortic size on the results of aortobifemoral bypass grafting. J Vasc Surg. Jun 2003;37(6):1219-1225.
  3. Green RM, Abbott WM, Matsumoto T, et al. Prosthetic above-knee femoropopliteal bypass grafting: five-year results of a randomized trial. J Vasc Surg. Mar 2000;31(3):417-425.
  4. Goodney PP, Beck AW, Nagle J, Welch HG, Zwolak RM. National trends in lower extremity bypass surgery, endovascular interventions, and major amputations. J Vasc Surg. Jul 2009;50(1):54-60.
  5. de Vries SO, Hunink MG. Results of aortic bifurcation grafts for aortoiliac occlusive disease: a meta-analysis. J Vasc Surg. Oct 1997;26(4):558-569.
  6. Criado E, Burnham SJ, Tinsley EA, Jr., Johnson G, Jr., Keagy BA. Femorofemoral bypass graft: analysis of patency and factors influencing long-term outcome. J Vasc Surg. Sep 1993;18(3):495-504; discussion 504-495.
  7. Hunink MG, Wong JB, Donaldson MC, Meyerovitz MF, Harrington DP. Patency results of percutaneous and surgical revascularization for femoropopliteal arterial disease. Med Decis Making. Jan-Mar 1994;14(1):71-81.
  8. Archie JP, Jr. Femoropopliteal bypass with either adequate ipsilateral reversed saphenous vein or obligatory polytetrafluoroethylene. Ann Vasc Surg. Sep 1994;8(5):475-484.
  9. Enzler MA, Ruoss M, Seifert B, Berger M. The influence of gender on the outcome of arterial procedures in the lower extremity. Eur J Vasc Endovasc Surg. May 1996;11(4):446-452.
  10. Magnant JG, Cronenwett JL, Walsh DB, Schneider JR, Besso SR, Zwolak RM. Surgical treatment of infrainguinal arterial occlusive disease in women. J Vasc Surg. Jan 1993;17(1):67-76; discussion 76-68.

 

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