Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.

Aortoiliac and Aortofemoral Bypass Graft Surgery

by Rosalyn Carson-DeWitt, MD
Definition

In a bypass, artificial tubes (grafts) are placed near a section of the blood vessel that is blocked or narrowed. The graft creates a path so that blood can move around the blockage. In this case, the grafts are placed on the aorta and the iliac or femoral arteries.

The aorta is the major artery that leaves the heart. It brings oxygen-rich blood to the body. At about the level of the belly button, the aorta divides into two iliac arteries. At the level of the groin, the iliac arteries become the femoral arteries.

Aortofemoral bypass is also called aorto bi femoral bypass. This is because the graft is formed in the shape of an upside down "y."

Most bypass surgery involves a traditional, open incision. Research is being done on how to do these operations through laparoscopic or mini-laparotomy techniques. They use much smaller incisions.

Reasons for Procedure

To have good blood flow to the lower part of the body, there must be good blood flow through the aorta, the iliac arteries, and the femoral arteries. Atherosclerosis is a disease in which sticky patches (plaques) build up along the walls of blood vessels. These plaques block the normal flow of blood within affected blood vessels. When the blood flow is decreased, the tissues on the other side of the blockage do not receive enough oxygen. This can result in the following:

  • The need for amputation of the leg
  • Cold feet or legs
  • Gangrene
  • Nerve damage
  • Nonhealing and/or infected sores (ulcers) on your legs or feet
  • Pain that increases the longer you walk or exercise (called intermittent claudication)
  • Scaly, dry, reddened, itchy, or brown skin on the legs or feet

This surgery can restore blood flow to the legs.

Possible Complications

If you are planning to have a bypass, your doctor will review a list of possible complications, which may include:

  • Bleeding
  • Complications from anesthesia
  • Infection
  • Nerve damage
  • Obstruction of the new graft by blood clots
  • Scarring

Factors that may increase the risk of complications include:

What to Expect
Prior to Procedure

Your doctor may do the following:

  • Angiography —Dye is injected into your arteries and x-ray pictures of your legs are taken. Because the dye will not be able to flow through areas narrowed or blocked by plaque, the specific location of blockages will be identified. Other types of minimally invasive angiography currently used also include CT angiography (CTA) and magnetic resonance angiography (MRA).
  • Ankle-brachial index—This test compares the blood pressure measurements in your arms and legs. These numbers should be very similar. If the numbers for your legs are much lower than those for your arms, this suggests a blockage in the arteries that carry blood through your legs.
  • Blood tests
  • Doppler ultrasound —This test uses sound waves to examine the blood flow in your arteries. It can determine which arteries are blocked.
  • Physical exam

Leading up to your procedure:

  • Arrange for help at home after you return from the hospital.
  • Arrange to have someone drive you home when you leave the hospital.
  • Do not eat or drink anything after midnight the night before your surgery.

Talk to your doctor about your medicines. You may be asked to stop taking some medicines up to one week before the procedure, like:

  • Blood thinners, such as clopidogrel (Plavix) or warfarin (Coumadin)
  • Aspirin or other anti-inflammatory drugs
Anesthesia

General anesthesia is used for this surgery. You will be asleep. A tube will be inserted into your throat to help you breathe.

Sometimes, an epidural anesthesia will be added. This anesthesia is injected into the spinal column. It will numb your body from the chest down.

Description of the Procedure

A large incision will be made in your abdomen. The muscles around your abdomen will be cut. To get to the blood vessels, some organs will need to be carefully moved out of the way.

Blood flow through the vessels will be briefly stopped. Clamps will be placed on either side of the blocked area to stop blood flow. The graft will be sewn into place. One end of the graft will be attached to the aorta just above the blockage. The other end will be attached just after the blockage on the femoral or iliac arteries.

The clamps will be removed. The doctor will watch to make sure there is good blood flow through the graft. Your internal organs will be put back into place. The abdominal muscles will be pulled together. The muscles will be stitched closed. The skin incision will be closed with either sutures or staples.

After Procedure

After the surgery, you will be brought to a recovery room. The tube in your throat may be removed, or it may need to stay in for a few days. The epidural anesthesia may also be continued for a few days. You will be monitored for any adverse reactions to the surgery or anesthesia.

How Long Will It Take?

About 3-4 hours

How Much Will It Hurt?

Anesthesia will block pain during the surgery. The large incision will cause pain after the surgery. You will be given pain medicine to help manage pain.

Average Hospital Stay

The usual length of stay is 5-7 days. The length will depend on your overall health and the speed of your recovery. Your doctor may choose to keep you longer if complications arise.

Post-procedure Care
At the Hospital

You will need to spend 1-2 days in bed after your operation.

  • An incentive spirometer, will be used every couple of hours during the day. This will keep your lungs as open as possible and help to avoid pneumonia .
  • A nasogastric (NG) tube may be placed during the operation. The tube is placed into your nose and down to your stomach. Your intestines often stop functioning normally after the surgery. You will not be able to eat anything by mouth until they begin to function again. The NG tube will then be removed. You will slowly progress from a liquid diet, to a soft foods diet, and finally to a regular diet.
  • You may also be given daily medicines to help avoid blood clots.
  • You will be monitored carefully in the intensive care unit (ICU). You may be there for 1-2 days as needed.
At Home

After the procedure, be sure to follow your doctor's instructions .

  • Ask your doctor about when it is safe to shower, bathe, or soak in water.
  • Follow your doctor’s directions regarding when you can begin to drive, exercise, lift things, and otherwise exert yourself.
  • Keep your incision clean and dry.
  • There is expected to be a dramatic improvement in your overall ability to walk or exercise.
  • You can expect to resume your normal activities within about six weeks of surgery.
Call Your Doctor

After you leave the hospital, contact your doctor if any of the following occurs: In case of an emergency, call for medical help right away.

  • Cough, shortness of breath or chest pain
  • Nausea and/or vomiting that you cannot control with the medicines you were given after surgery, or which persist for more than two days after discharge from the hospital
  • Pain or swelling in your legs, calves, or feet
  • Pain that you cannot control with the medicines you have been given
  • Pain, burning, urgency or frequency of urination, or persistent bleeding in the urine
  • Redness, swelling, increasing pain, excessive bleeding, or any discharge from the incision site
  • Signs of infection, including fever and chills
  • Your leg becomes cold, pale, blue, tingly, or numb

Last reviewed: December 2011 by David N. Smith, MD.

RESOURCES:
CANADIAN RESOURCES:
References:
  • Braunwald E. Zipes DP, Libby P, Bonow R, eds. Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine . 7th ed. St. Louis, MO: WB Saunders Co; 2005.
  • Townsend CM, Beauchamp DR, Evers MB, Mattox KL, Sabiston DC, eds. Sabiston Textbook of Surgery . 17th ed. St. Louis, MO: WB Saunders Co; 2004.