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Definition

Peripheral artery bypass is surgery to reroute the blood supply around a blocked artery in one of your legs. Fatty deposits can build up inside the arteries and block them.

A graft is used to replace or bypass the blocked part of the artery. The graft may be a plastic tube, or it may be a blood vessel (vein) taken from your body (most often the opposite leg) during the same surgery.

Description

Peripheral artery bypass surgery can be done in one or more of the following blood vessels:

• Aorta (the main artery that comes from your heart)
• Artery in your hip
• Artery in your thigh
• Artery behind your knee
• Artery in your lower leg
• Artery in your armpit

During bypass surgery of any artery:

• You will receive medicine (anesthesia) so that you do not feel pain. The kind of anesthesia you receive will depend on what artery is being treated.
• Your surgeon will make a cut over the part of the artery that is blocked.
• After moving skin and tissue out of the way, the surgeon will place clamps at each end of the blocked section of artery. The graft is then sewn in place.
• The surgeon will make sure you have good blood flow in your extremity. Then your cut will be closed. You may have an x-ray called an arteriogram to make sure that the graft is working.

If you are having bypass surgery to treat your aorta and iliac artery or your aorta and both femoral arteries (aortobifemoral):

• You will probably have general anesthesia. This will make you unconscious and unable to feel pain. Or, you may have epidural or spinal anesthesia instead. The doctor will inject your spine with medicine to make you numb from your waist down.
• Your surgeon will make a surgical cut in the middle of the abdomen to reach the aorta and iliac arteries.

If you are having bypass surgery to treat your lower leg (femoral popliteal):

• You may have general anesthesia. You will be unconscious and unable to feel pain. You may instead have an epidural or spinal anesthesia. The doctor will inject your spine with medicine to make you numb from your waist down. Some people have local anesthesia and a medicine to relax them. Local anesthesia numbs just the area being worked on.
• Your surgeon will make a cut in your leg between your groin and knee. It will be near the blockage in your artery.

Why the Procedure Is Performed

Symptoms of a blocked peripheral artery are pain, achiness, or heaviness in your leg that starts or gets worse when you walk.

You may not need bypass surgery if these problems happen only when you walk and then go away when you rest. You may not need this surgery if you can still do most of your everyday activities. Your health care provider can try medicines and other treatments first.

Reasons for having arterial bypass surgery of the leg are:

• You have symptoms that keep you from doing your everyday tasks.
• Your symptoms do not get better with other treatment.
• You have skin ulcers (sores) or wounds on your leg that do not heal.
• You have an infection or gangrene in your leg.
• You have pain in your leg from your narrowed arteries, even when you are resting or at night.

Before having surgery, your provider will do special tests to see the extent of the blockage.

Risks

Risks for any anesthesia and surgery are:

• Allergic reactions to medicines
• Blood clots in the legs that may travel to the lungs
• Breathing problems
• Heart attack or stroke

Risks for this surgery are:

• Bypass does not work
• Damage to a nerve that causes pain or numbness in your leg
• Damage to nearby organs in the body
• Damage to the bowel during aortic surgery
• Excess bleeding
• Infection in the surgical cut
• Injury to nearby nerves
• Sexual problems caused by damage to a nerve during aortofemoral or aortoiliac bypass surgery
• Surgical cut that opens up
• Need for a second bypass surgery or a leg amputation
• Heart attack
• Death

Before the Procedure

You will have a physical exam and many medical tests.

• Most people need to get their heart and lungs checked before they have peripheral artery bypass.
• If you have diabetes, you will need to see your provider to have it checked.

Always tell your provider what medicines you are taking, even drugs, supplements, or herbs you bought without a prescription.

During the 2 weeks before your surgery:

• You may be asked to stop taking drugs that make it harder for your blood to clot. These include aspirin, ibuprofen (Advil, Motrin), clopidogrel (Plavix), naprosyn (Aleve, Naproxen), and other similar drugs.
• Ask your provider which drugs you should still take on the day of your surgery.
• If you smoke, you need to stop. Ask your provider for help.
• Always let your provider know about any cold, flu, fever, herpes breakout, or other illness you may have before your surgery.

DO NOT drink anything after midnight the night before your surgery, including water.

On the day of your surgery:

• Take the medicines your provider told you to take with a small sip of water.
• Your provider will tell you when to arrive at the hospital.

After the Procedure

Right after surgery, you will go to the recovery room, where nurses will watch you closely. After that you will go either to the intensive care unit (ICU) or a regular hospital room.

• You may need to spend 1 or 2 days in bed if the surgery involves the large artery in your abdomen called the aorta.
• Most people stay in the hospital for 4 to 7 days.
• After femoral popliteal bypass, you will spend less time or no time in the ICU.

When your surgeon says it is OK, you will be allowed to get out of bed. You will slowly increase how far you can walk. When you are sitting in a chair, keep your legs raised on a stool or another chair.

Your pulse will be checked regularly after your surgery. The strength of your pulse will show how well your new bypass graft is working. While you are in the hospital, tell your provider right away if the leg that had surgery feels cool, looks pale or pink, feels numb, or if you have any other new symptoms.

You will receive pain medicine if you need it.

Outlook (Prognosis)

Bypass surgery improves blood flow in the arteries for most people. You may not have symptoms anymore, even when you walk. If you still have symptoms, you should be able to walk much farther before they start.

If you have blockages in many arteries, your symptoms may not improve as much. The prognosis is better if other medical conditions such as diabetes are well controlled. If you smoke, it is very important to quit. 

References

Bonaca MP, Creager MA. Peripheral artery diseases. In: Libby P, Bonow RO, Mann DL, Tomaselli GF, Bhatt DL, Solomon SD, eds. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 12th ed. Philadelphia, PA: Elsevier; 2022:chap 43.

Kinlay S, Bhatt DL. Treatment of noncoronary obstructive vascular disease. In: Libby P, Bonow RO, Mann DL, Tomaselli GF, Bhatt DL, Solomom SD eds. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 12th ed. Philadelphia, PA: Elsevier; 2022:chap 44.

Society for Vascular Surgery Lower Extremity Guidelines Writing Group; Conte MS, Pomposelli FB, et al. Society for Vascular Surgery practice guidelines for atherosclerotic occlusive disease of the lower extremities: management of asymptomatic disease and claudication. J Vasc Surg. 2015;61(3 Suppl):2S-41S. PMID: 25638515 pubmed.ncbi.nlm.nih.gov/25638515/.

Writing Committee Members, Gerhard-Herman MD, Gornik HL, et al. 2016 AHA/ACC Guideline on the management of patients with lower extremity peripheral artery disease: executive summary. Vasc Med. 2017;22(3):NP1-NP43. PMID: 28494710 pubmed.ncbi.nlm.nih.gov/28494710/.

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