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Lower Extremity Bypass

What is surgical bypass?

Raleigh, NC Surgical Bypass doctorsBypass grafts in the leg

Surgical bypass treats your narrowed (or enlarged) arteries by directly creating a detour, or bypass, around a section of the artery that is blocked or enlarged. Your arteries are normally smooth and unobstructed on the inside but they can become blocked through a process called atherosclerosis, which means hardening of the arteries. As you age, a sticky substance called plaque can build up in the walls of your arteries. Cholesterol, calcium, and fibrous tissue make up the plaque. As more plaque builds up, your arteries can narrow and stiffen. Eventually, as the process progresses, your blood vessels can no longer supply the oxygen demands of your organs or muscles, and symptoms may develop.

During a bypass procedure, we create a new pathway for blood flow using a graft. A graft can be a portion of one of your veins or a man-made synthetic tube that we connect above and below a blockage to allow blood to pass through it and around the blockage.

You may be familiar with bypass surgery on heart arteries, but we also use similar bypasses to treat peripheral arterial disease (PAD). We use bypasses most commonly to treat leg artery disease, which is hardening of the arteries in the leg.

How do I know if I need a bypass?

First we ask you questions about your general health, medical history, and symptoms. In addition, we conduct a detailed physical exam. Together, the questions and examination are known as a patient history and exam. We will also want to know when your symptoms occur and how often.

Next, we will order tests to locate the blockage and choose the best places to connect the graft. These tests include:

  • Duplex ultrasound, which is a non-invasive test that uses high-frequency sound waves to measure real-time blood flow and detect blockages or other abnormalities in the structure of your arteries
  • Magnetic resonance angiography (MRA), which uses magnetic fields and radio waves to show blockages inside your arteries
  • Computerized tomographic angiography (CTA), which uses contrast dye and x rays (essentially a specialized CT scan), to show blockages inside your arteries
  • Angiography, which produces x-ray pictures of the blood vessels in your legs using a contrast dye that is injected to highlight your arteries

We may order segmental blood pressures or pulse volume recording to determine the narrowing of the arteries in your arm or leg. If you have had a heart attack in the past, or if you have chest pain, we might recommend a stress test or, possibly, a heart catheterization.

We will give you the necessary instructions you need to follow before the surgery, such as fasting. Usually, your physician will ask you not to eat or drink anything 8 hours before your procedure. Your physician will discuss with you whether to reduce or stop any medications that might increase your risk of bleeding or other complications.

Am I a candidate for bypass surgery?

If you have symptoms of atherosclerosis, you may be a candidate for bypass surgery. Symptoms can range from pain in the arms or legs during activity, called intermittent claudication, to the development of non-healing ulcers or gangrene (tissue death) in more severe cases. You still may be a candidate for bypass surgery even if you are not eligible for angioplasty and stenting.

Am I at risk for complications during procedure?

Factors that increase your chances of complications include:

  • High blood pressure
  • Obesity
  • High cholesterol
  • Coronary artery disease
  • Chronic obstructive pulmonary disease, such as emphysema
  • Poor kidney function
  • Diabetes
  • Smoking

What happens during surgical bypass?

Your specific surgical procedure depends on your symptoms, your overall physical condition, and how much plaque has built up in your arteries. We, together with your anesthesiologist, may recommend either general or regional (epidural or spinal) anesthesia for the procedure.

Although the particular details may vary, in general for an arm or leg bypass, we usually first select and remove the vein that will serve as the bypass graft for your artery. We usually uses your greater saphenous vein (GSV) for the graft, if it is suitable. Your GSV runs under your skin between your foot and your groin. Sometimes we may need to use another vein or a synthetic fabric artery for the graft if your GSV is unavailable or unsuitable.

What can I expect after surgical bypass?

Your hospital stay may range from about 3 to 10 days. We will remove staples or stitches from the incisions, usually about 7 to 14 days after your operation, after you leave the hospital. You may need assistance from a visiting nurse, home health aide, or physical therapist when you first go home.

If you develop fevers, a cold painful arm or leg, or if your incision area becomes extremely red, swells, or begins draining, you should contact us immediately. These may be signs of developing infection or other problems.

If you have PAD (see COMMON VASCULAR CONDITIONS), we may also recommend that you take an antiplatelet medication, such as aspirin, which can help prevent blood clots.

Are there any complications?

Complications from bypass surgery include blockage of the bypass, bleeding from the incision or infection, are potentially more serious. We will discuss the important risks and benefits with you and answer your particular questions.

What if my bypass fails?

Unfortunately, bypass grafts sometimes fail; we must sometimes remove a limb (or part of a limb) that is painful or threatens your health. Amputations are most commonly performed on the toes, legs or arms. urgeons (and patients) consider amputation a last resort.

The most common reason you may need an amputation is if you have peripheral arterial disease (PAD) due to atherosclerosis (hardening of the arteries). In PAD, the blood vessels in your limbs become damaged because of hardening of the arteries or diabetes. When our blood vessels are unable to supply blood and oxygen to your fingers or toes, the cells and tissues die (i.e. gangrene) and are vulnerable to infection.

What is an amputation?

Raleigh, NC amputation surgery

A bilateral leg amputee competing in the London Olympics 2012

When do I need amputation?

PAD or “hardening of the arteries” is the leading cause of amputation in people age 50 and older, and accounts for up to 90 percent of amputations overall. Vascular Surgeons have unique expertise in limb salvage procedures. However, if these treatments do not work, or if the tissue damage is too far advanced initially, amputation will remove a source of major infection and may be necessary to save your life.

How do I prepare?

Our Vascular Surgeons will perform a physical examination to determine whether your limb can be saved or if you need an amputation. Common signs of ischemia (or lack of blood flow) include:

  • Cool skin near your wound
  • Extremely painful skin
  • Wound odor
  • Infected or non-healing sores or wounds

Our surgeons will also test your physical strength, balance, and coordination to assess your potential for rehabilitation. If you are going to use an artificial limb, we will arrange for you to be evaluated by a certified orthotist.

We will discuss with you whether to reduce or stop any medications that might increase your risk of bleeding or other complications.

Am I at risk for complications during amputation?

If you have other conditions, like diabetes or heart disease, you have a higher risk of complications from an amputation. Having a very serious traumatic injury also increases your risk of complications. Above-the-knee amputations can be associated with more risk than below-the-knee amputations, because people who require above-the-knee amputations are more likely to be in poorer health. Depending upon your particular situation, your physician will attempt to save as much of your limb as is possible.

What happens during amputation?

To perform an amputation, your physician must remove your diseased limb but preserve as much healthy skin, blood vessel, and nerve tissue as possible.

During the operation, our surgeons may decide that more of your limb needs to be removed if the edges of your skin do not bleed enough to allow them to heal. When we divide the muscles, we will shape them to make sure that your stump has a comfortable contour for your artificial limb. We also divide and protect your nerves, so that they are not exposed and painful.

Our surgical team will place a stocking over your stump to hold drainage tubes and wound dressings, or your limb may be placed in traction, or a splint, depending upon your particular situation.

What can I expect after amputation?

After your surgery, you will stay in the hospital for approximately 3-5 days. We will monitor your medical condition and determine when you are ready for discharge from the hospital.  If you need pain medications or antibiotics, we will prescribe them. Ideally, your wound should fully heal in about 4 to 8 weeks after your surgery.

If your condition permits, you will receive physical therapy soon after your surgery. Physical therapy includes gentle stretching for the first 2 or 3 days. Later, you will perform exercises, such as getting in and out of your bed or in and out of your wheelchair. Eventually, you will learn how to bear your weight on your remaining limb.

You may experience phantom pain (a sense of feeling pain in your amputated limb) or other emotional concerns, such as grief over the lost limb, after surgery. If this is the case, we will recommend counseling or drug therapy, as appropriate. Don’t despair! Patients can return to an active lifestyle after amputation

North Carolina amputation surgery

 Are there any complications?

You may have complications following any surgical procedure. Complications that occur specifically from amputation include a joint deformity called contracture, a severe bruise called a hematoma, death of the skin flaps (necrosis), wound opening from poor healing, or infection. We can treat all of these complications. Occasionally, you may need to undergo further surgical treatment or another amputation procedure.

What can I do to stay healthy?

Unfortunately, amputation does not stop plaque from building up in your remaining arteries. To prevent hardening of the arteries from affecting other parts of your body, including your heart, you should consider the following changes:

  • Eat more foods low in saturated fat, cholesterol, and calories
  • Exercise regularly
  • Maintain your ideal body weight
  • Avoid smoking

You can learn how to adapt to having an artificial limb, including getting regular exercise, with the help of physical therapy. Studies have found that amputees who engage in regular physical exercise feel better about themselves than those who are more sedentary. Also, people who recover from an amputation are more likely to have greater job satisfaction, possibly because of changes in their attitudes regarding life goals.