PERIPHERAL VASCULAR BYPASS SURGERY 2

Peripheral vascular bypass surgery: 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.

Preparation
If not done earlier in the diagnostic process, ultrasonography or angiography procedures may be performed when the patient is admitted to the hospital. These tests help the physician evaluate the amount of plaque and exact location of the narrowing or obstruction. Any underlying medical condition, such as high blood pressure, heart disease, or diabetes is treated prior to bypass surgery to help obtain the best surgical result. Regular medications, such as blood pressure drugs or diuretics, may be discontinued in some patients. Routine pre-operative blood and urine tests are performed when the patient is admitted to the hospital.

Aftercare
After bypass surgery, the patient is moved to a recovery area where blood pressure, temperature, and heart rate are monitored for an hour or more. The surgical site is checked regularly. The patient is then transferred to a concentrated care unit to be observed for any signs of complications. The total hospital stay for femoropopliteal bypass or femorotibial bypass surgery may be two to four days. Recovery is slower with aortobifemoral bypass surgery, which involves abdominal incisions, and the hospital stay may extend up to a week. Walking will begin immediately for patients who have had femoropopliteal or femorotibial bypasses, but patients who have had aortobifemoral bypass may be kept in bed for 48 hours.

When bypass patients go home, walking more each day, as tolerated, is encouraged to help maintain blood flow and muscle strength. Feet and legs can be elevated on a footstool or pillow when the patient rests. Some swelling of the leg should be expected; it does not indicate a problem and will resolve within a month or two.

During recuperation, the patient may be given pain medication if needed, and clot prevention (anticoagulant) medication. Any redness of the surgical site or other signs of infection will be treated with antibiotics. Patients are advised to reduce the risk factors for atherosclerosis in order to avoid repeat narrowing or blockage of the arteries. Repeat stenosis (restenosis) has been shown to occur frequently in people who do not make the necessary lifestyle modifications, such as changes in diet, exercise, and smoking cessation. The benefits of the bypass surgery may only be temporary if underlying disease, such as atherosclerosis, high blood pressure, or diabetes, is not also treated.

Risks
The risks associated with peripheral vascular bypass surgery are related to the progressive atherosclerosis that led to arterial occlusion, including a return of pre-operative symptoms. In patients with advanced PAD, heart attack or heart failure may occur. Build up of plaque has also taken place in the patient’s arteries of the heart. Restenosis, the continuing build up of plaque, can occur within months to years after surgery if risk factors are not controlled.

Other complications may include:
• clot formation in a saphenous vein graft
• failed grafts or blockages in grafts
• reactions to anesthesia
• breathing difficulties
• embolism (clot from the surgical site traveling to vessels in the heart, lungs, or brain)
• changes in blood pressure
• infection of the surgical wound
• nerve injury (including sexual function impairment after aortobifemoral bypass)
• post-operative bleeding
• failure to heal properly

Normal results
A femoropopliteal or femorotibial bypass with an autogenous graft of good quality saphenous vein has been shown to have a 60–70% chance of staying open and functioning well for five to 10 years. Aortobifemoral bypass grafts have been shown to stay open and reduce symptoms in 80% of patients for up to 10 years. Pain and walking difficulties should be relieved after bypass surgery. Success rates improve when the underlying causes of atherosclerosis are monitored and managed effectively.

Morbidity and mortality rates
The risk of death or heart attack is about 3–5% in all patients undergoing peripheral vascular bypass surgery. Following bypass surgery, amputation is still an outcome in about 40% of all surgeries performed, usually due to progressive atherosclerosis or complications caused by the patient’s underlying disease condition.

Alternatives
Peripheral vascular bypass surgery is a mechanical way to reroute blood, and there is no alternative method. Alternative ways to prevent plaque build-up and reduce the risk of narrowing or blocking the peripheral arteries include nutritional supplements and alternative therapies, such as:
• Folic acid can help lower homocysteine levels and increase the oxygen-carrying capacity of red blood cells.
• Vitamins B6 and B12 can help lower homocysteine levels.
• Antioxidant vitamins C and E work together to promote healthy blood vessels and improve circulation.
• Angelica, an herb that contains coumadin, a recognized anticoagulant, which may help prevent clot formation in the blood.
• Essential fatty acids, as found in flax seed and other oils, to help reduce blood pressure and cholesterol, and maintain blood vessel elasticity.
• Chelation therapy, used to break up plaque and improve circulation.