Definition

Both aortoiliac bypass and aortofemoral bypass are operations in which grafts (artificial tubes) are sutured into place to create a path around an area of the aorta and/or the iliac artery which is narrowed or blocked.

The aorta is the major artery that leaves the heart [3], allowing oxygenated blood to flow throughout the body. About the level of the belly button, the aorta divides into two iliac arteries, which then become the femoral arteries at the level of the groin.

Aortofemoral bypass is also called aorto bi femoral bypass, since the new graft is formed in the shape of an upside down "y", with the top part attaching to the aorta and the lower parts attaching to each of the femoral arteries.

Although most bypass surgery involves a traditional, open incision, research is being done on how to perform these operations through much smaller incisions, using a scope to view the parts internally ( laparoscopic [4] or mini-laparotomy technique).

Aortoiliac Bypass

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© 2008 Nucleus Medical Art, Inc.


Parts of the Body Involved

  • Aorta
  • Iliac or femoral arteries

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 [5] is a disease in which sticky patches (plaques) of calcium, fibrous tissue, and cholesterol [6] 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:

  • Pain, which increases the longer you walk or exercise [7] (called intermittent claudication)
  • Cold feet or legs
  • Scaly, dry, reddened, itchy, or brown skin of the legs or feet
  • Nonhealing and/or infected sores (ulcers) in the skin of your legs or feet
  • Gangrene [8]
  • Amputation [9] of gangrenous limbs
  • Nerve damage

Risk Factors for Complications During the Procedure


What to Expect

Prior to Procedure

Your doctor will likely do the following:

  • Physical exam
  • Blood tests—Blood tests are done to make sure that you do not have an infection, to make sure that your blood is clotting properly, and to determine your blood type in case you need a transfusion during or after surgery.
  • 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 significantly lower than those for your arms, this suggests a blockage in the arteries that carry blood through your legs.
  • Doppler ultrasound [14] —This test uses sound waves to examine the blood flow in your arteries. It can determine which arteries are blocked.
  • Angiography [15] —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 [16] (CTA) and magnetic resonance angiography [17] (MRA).

In the days leading up to your procedure:

  • Review your regular medications with your surgeon; you may need to stop taking certain drugs, especially blood thinners.
  • Do not eat or drink anything after midnight the night before your surgery, unless told otherwise by your doctor.
  • Arrange for help at home after you return from the hospital.
  • Arrange to have someone drive you home when you leave the hospital.
  • Wear comfortable clothing.

Anesthesia

Aortic surgery is performed under general anesthesia [18] . Occasionally, epidural anesthesia will be added for postoperative pain [19] control. You will usually be given medications through an intravenous line to help you relax.

When you receive general anesthesia, you will initially breathe anesthetic gases through a mask. A tube will then be inserted into your trachea (windpipe) so that a breathing machine can be used during the operation. At the end of the procedure, you may need to keep the tube in your trachea for a few hours or even a day or more. It will eventually be removed.

If you are also receiving epidural anesthesia, a tiny catheter tube will be placed in an area of your spine and numbing medication will be administered into your spine. This will cause your entire body to be totally numb below the area of the catheter tube.

Description of the Procedure

After you are well-anesthetized, a large incision will be made in your abdomen. The blood vessels that need to be operated on lie deep in many of your internal organs, so these organs will need to be carefully moved out of the way.

Blood flow through the vessels that are going to be operated on will be briefly stopped with clamps on either side of the area of blockage. A graft made of artificial material will be sewn into place on either the iliac artery or the femoral artery, in an area clear of obstructive plaque. The other end of the graft will be attached to the aorta just above the area where the blockage begins.

The clamps that were placed on the blood vessels being operated on will be removed. The surgeon will observe briefly to ensure that there is good blood flow through the new graft. Your internal organs will be repositioned properly. The abdominal muscle [20] will be pulled together and stitched closed. The skin incision will be closed with either sutures or staples.

After Procedure

You will need to spend 1-2 days in bed after your operation. You will probably remain in the hospital for 5-7 days altogether.

How Long Will It Take?

Aortoiliac and aortofemoral bypass surgery usually takes about 3-4 hours.

Will It Hurt?

Because aortoiliac bypass and aortofemoral bypass surgery require a large abdominal incision, there will be pain [19] after the operation. You will be given pain [19] medication to help make you as comfortable as possible for several days following the surgery. Sometimes the epidural catheter will be left in place for a few days to relieve the pain [19].

Possible Complications

  • Infection of the incision site or the graft itself
  • Obstruction of the new graft by blood clots
  • Bleeding
  • Complications from anesthesia
  • Pneumonia [21]
  • Scarring
  • Heart attack [22]
  • Stroke [23]
  • Sexual problems if nerves in the pelvic area are damaged during surgery

Average Hospital Stay

You will be in the hospital for 5-7 days, depending on how you progress and whether you were debilitated prior to the surgery.

Postoperative Care

  • Pain medication will be given either through your intravenous (IV) or through the epidural catheter if one was placed.
  • You will be monitored carefully in the intensive care unit (ICU) for one or two days as needed.
  • An incentive spirometer, will be used every couple of hours during the day to make sure that you are breathing deeply and keeping the tiny sacs within your lungs as open as possible. This can help you avoid the complication of pneumonia [21] .
  • A nasogastric (NG) tube may be placed during the operation to suction the fluid from your stomach. Because your intestines probably stopped normal functioning during the operation, you won’t be able to take anything by mouth until they begin functioning again. The NG tube will then be removed and at that point, you will slowly progress through a liquid diet to a soft foods diet to a regular diet.
  • You may be given a small dose of aspirin daily to help you avoid blood clots.

Outcome

  • You can expect to resume your normal activities within about six weeks of surgery.
  • There is expected to be a dramatic improvement in your overall ability to walk or exercise [7] compared to your preoperative state.
  • Follow your doctor’s directions regarding when you can begin to drive, exercise [7], lift things, and otherwise exert yourself.

Call Your Doctor If Any of the Following Occurs

  • Fever, chills
  • Cough [24] , especially if it produces of sputum
  • Shortness of breath
  • Chest pain [19]
  • Redness, swelling, or hotness around the site of your incision; discharge from the site of the incision
  • Nausea, vomiting
  • Difficulty urinating, or pain [19], burning, frequency, urgency, or bleeding with urination
  • Pain and/or swelling in your feet, calves, or legs