Advice after your nerve block for surgery
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Why do patients need to undergo arterial bypass surgery?
Peripheral arterial disease (PAD) can block or narrow your leg arteries, reducing the circulation of blood to the legs. This becomes particularly noticeable when your leg muscles require more blood during walking but the poor blood supply gives rise to leg pains. Other signs of poor circulation include pain in the feet at night when lying in bed or when trying to elevate the legs. Any worsening in the flow of blood may lead to constant pain (rest pain) with the risk of ulcers or gangrene developing.
Arterial bypass surgery is done to improve the blood supply to your leg in order to relieve pain and to heal any tissue damage. Arterial bypass surgery is only performed as a final resort when it is not possible to stretch open your diseased and blocked artery using a balloon (angioplasty).
What happens before the operation?
A CT angiogram (CTA) or Magnetic Resonance Angiogram (MRA) of your leg arteries is done to obtain an accurate “roadmap” of your arteries for planning the operation.
You will also undergo an ultrasound scan of your legs and arms for "Vein Mapping" to look for a suitable vein that can be used as a substitute blood vessel for carrying out the bypass operation. Before the bypass operation, you will be asked to attend a preadmission clinic before surgery in order for tests to be performed to ensure you are fit for the operation. This will usually include an ECG, a chest X-Ray and blood tests.
We may ask for you to be seen by a vascular anaethetist, in order to assess your levels of fitness prior to surgery, who will thenreport back to the vascular MDT.
Following these tests, you will be admitted to hospital on the morning of your operation. Some patients are admitted urgently as an emergency and will have all these pre-operative tests performed as inpatients.
What happens when you arrive in hospital?
Please bring with you all the medications you are already taking. You will be admitted to your bed by one of the nurses who will note down all your personal details. The Vascular Surgeons and the Vascular Anaesthetists will see you before surgery to answer any last minute questions about your operation and obtain informed consent from you for your surgery.
What happens during the arterial bypass operation?
You will be taken to the anaesthetic room and from there into the operating theatre. An epidural (injection into the back) may be performed to numb the lower half of your body during surgery and to provide pain control after surgery. Some patients undergo this operation awake with the epidural.
In other patients, a general anaesthetic will be given to put them to sleep before surgery. All patients will have a urinary catheter inserted into their bladder to drain urine. A cannula will be inserted into a vein in your arm to ensure that you are given adequate fluids during and following surgery.
An arterial line may be inserted into one of the arteries in the wrist to monitor blood pressure during the operation and in the recovery phase, this is done in the anaesthetic room. Cuts will be made in the skin in your groin and further down the thigh, calf or even foot to harvest the leg vein to be used as a substitute blood vessel (graft) for the bypass surgery.
Sometimes, when a vein is not available, a plastic tube is used instead. The vein or tube graft is joined to the artery at groin level and to the best available artery below the level of the diseased arteries with very fine stitches.
If there are toes that have been severely damaged by infection or poor blood supply (gangrene) and there is no hope of their recovery, it may be necessary to remove the dead or infected part. This will be explained to you before the operation.
What are the risks of arterial bypass surgery?
The main complication is an early blocked graft which will put your leg at risk of amputation if it is not corrected. If this happens, it will usually be necessary to perform a further operation to clear the blocked graft. Approximately one in twenty patients will experience this difficult complication. Graft surveillance is carried out on patients who have received a vein graft, this is carried out in the Vascular Lab post operatively, after 4 weeks, 3 months, 6 months and a year.
Other complications such as a heart attack, stroke, kidney failure, chest infection or wound infection may occasionally occur. When there is significant bleeding during the operation, a blood transfusion may be required.
Although most patients (97%) will make a full recovery from this operation, some patients may have a fatal complication from their surgery. This happens in about 3% of patients undergoing arterial bypass surgery.
Medications and Surgery
Angiotensin-converting enzyme inhibitors or ACE inhibitors (e.g., Enalapril, Lisinopril or Ramipril) should not be taken on the day of surgery.
Angiotensin II receptor blockers or ARBs (e.g., Candesartan, Losartan or Valsartan) should not be taken on the day of surgery.
Clopidogrel should be stopped 7 days pre-operatively for vascular operations except for all carotid endarterectomies or unless directed by your consultant. If you have had a stent inserted into your heart in the last 12 months, please inform your consultant and this will be discussed with a cardiologist as to the decision of when to stop your Clopidogrel.
Warfarin. If you are currently taking Warfarin this will be discussed with you by your consultant, regarding if this needs to be stopped and if you need a covering anticoagulant.
Direct oral anticoagulants or DOAC (e.g., Rivaroxiban, Apixaban or Dabigatran). This should be stopped at least 48hrs prior to the procedure if there is high risk of bleeding. If your kidney function is abnormal, this may need to be discontinued for a longer time period prior to surgery. If you take Ticagrelor it will need to be discontinued for 5 days.
Your consultant will advise about this.
Following the procedure, the DOAC will be restarted after 24-72 hours at the discretion of your consultant. You will be started on an anticoagulation injection (e.g., Dalteparin) to help prevent blood clots on the evening of the procedure and daily until the DOAC is restarted. This will be stopped once the DOAC has been restarted.
T.E.D Anti-embolism stockings should never be given for arterial patients unless specifically directed by the consultant, if you are asked to apply a pair please can you question this with a member of the vascular team.
Along with toiletries, night clothes, etc., the vascular team actively encourages all our patients to bring in day clothes to wear on the ward whilst an inpatient and to have ready for discharge.
What happens when you are discharged home?
It is normal for your leg to swell after this operation because of the improved blood supply. This will persist for up to 3 months. You are advised to elevate your leg on a stool when sitting at rest. You are likely to feel tired for some weeks after your bypass operation but this should gradually improve with time. Regular exercise such as a short walk is recommended for the first few weeks following surgery followed by a gradual return to your normal activity. Most patients will return to normal full activity within 6 to 12 weeks following bypass surgery.
You will be safe to drive when you can perform an emergency brake procedure without too much discomfort. This will normally be 4-6 weeks after surgery.
Once discharged home you may receive an appointment for a scan of your graft, if you have had a vein graft. You should receive an appointment to see the consultant 6-8 weeks post operatively.
Should you develop any reoccurance of the pain you had prior to your operation or develop a cold painful limb it is imperative you contact the vascular department to be seen urgently.
The community nurses will review your wound. Should they or yourself have any concerns, they should contact the vascular team (the numbers are on the opposite page).
Increasing pain, redness or foul smelling discharge should be immediately reviewed.
It is vitally important you maintain good hygiene, particularly to the groin wounds; your nurses will advise you on washing, showering and bathing, depending on how your wound is progressing.
What can I do to make my arterial bypass graft last longer?
If you smoke, it is very important that you make a sincere and determined effort to give up completely. Help may be available from the Smoking Cessation Clinic. Smoking reduces the life of your arterial bypass graft significantly.
General measures such as weight reduction, a low fat diet and regular exercise are also important. You should also take your prescribed medications without fail.
Research
The Vascular Team at Frimley Health are actively involved in vascular research projects. You may be asked to participate in a research project as a patient if you are felt to be suitable.
Your data may also be used for the National Vascular Registry if you require certain operations or procedures.
Should you have concerns about your personal data and its use, please discuss with your clinician involved in your care. Data is entered automatically to the national database unless you notify
us of your dissent.
Contact Details
Secretaries at Frimley Park
Mr D J Gerrard, Mr Chong, Mr Chaudary 03006132141
Mr K Jones, Mr Cleanthis, Miss Moore 03006134291
Lt Col Sharrock, Mr Ali, Mr Dastur 03006132487
North Hants Hospital Basingstoke Secretary
Wexham Park Hospital Secretary
Vascular Specialist Nurses
Claire Martin Lead Vascular CNS - FPH 0300 6136302
Tracey Craig Vascular CNS - FPH
Andrea Croucher Vascular CNS - FPH
Pabita Limbu Vascular CNS - FPH
Kirstie Lane Vascular CNS - WPH 07770702053
Nessa Cababa Vascular CNS - ASPH 07522618600
Contact us
If you have any queries relating to this information, please contact the Vascular surgery service.
About this information
Service:
Vascular surgery
Reference:
Y/038
Approval date:
7 March 2024
Review date:
1 March 2027
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Important note
This page provides general information only. It is developed by clinical staff and is reviewed regularly every 3 years for accuracy. For personal advice about your health, or if you have any concerns, please speak to your doctor.