Overview

 

The majority of patients with hardening of the arteries in the legs do not require surgery (see intermittent claudication). Most patients have a degree of disability which is manageable by adjustments in lifestyle. Treating vascular risk factors reduces the risk of further problems due to atherosclerosis.

Hardening of the arteries in the legs only leads to serious problems in a small number of patients. However, if hardening of the arteries progresses, then there may be a risk of amputation.

Arterial bypass surgery is indicated in patients with a threatened leg likely to require amputation if left untreated (critical limb ischaemia). It can also be considered in patients with very severe disabling claudication. Arterial bypass surgery can save the leg or reverse severe disability. The benefits of bypass surgery in patients with life style limiting claudication are more controversial. Many surgeons will advise against such surgery in these circumstances as surgery may precipitate problems as well as solve them.

Arterial bypass surgery is not minor surgery. Operations are frequently prolonged, complex and carry significant risks. A decision to proceed with an operation to improve the blood supply to a leg needs to be taken in a careful and considered way. It will be the right option for many patients. In other patients an amputation may be more appropriate. In some very sick patients nearing the end of their lives the compassionate option may be to avoid any type of treatment and to allow the patient to die peacefully.

Symptoms

Rest pain - this is a severe, continuous pain felt in the toes and foot. Some patients find that they only experience this pain at night. This is because during the day when the leg is down, gravity can assist the flow of blood. When the leg is elevated at night this gravity assistance disappears. Many patients find that dangling the foot over the edge of the bed can help to ease the pain. The pain is often very severe, and patients will sleep in a chair to avoid the discomfort of elevating the leg.

Gangrene - if the blood supply deteriorates to a stage where insufficient blood is available to keep the tissues alive then gangrene can develop, as shown (below right) in the 2nd toe (previous big toe amputation). This means that the tissue has died and turns black. If the tissues remain dry (mummified) then sometimes a toe can autoamputate and drop off without surgery. If it becomes wet (infected) then surgery is frequently required.

Ulceration and loss of tissue - sometimes frank gangrene does not develop but the tissues can ulcerate. In this situation the superficial tissues die and are shed leaving an ulcer crater which will not heal because the blood supply is so poor. This is shown in the picture (below left) in which an ulcer has developed on the outside of the foot due to a poor blood supply. Severe disabling claudication - some patients experience none of the above symptoms but they can develop claudication symptoms after a few steps and managing a normal life becomes virtually impossible.

Complications

As with any operation that is done under general anaesthetic, there is a risk of complications related to your heart and lungs. The tests that you will have before the operation will make sure that you can have the operation in the safest possible way and will reduce the chances for such complications. It is important to have the operation as soon as possible. If you delay things then the condition of your leg will get worse and it may become infected necrotic (go dead). This can make you very ill and significantly increase the chances of complications during the operation.

Complications are rapidly recognised and dealt with by the surgical staff. If you think that all is not well, please let the doctors and nurses know. Sometimes there is some bleeding under the wounds which causes more severe bruising. This settles down. However, there is a small chance of severe bleeding in the area of the operation that might require another operation to stop it. Sometimes the blood in the bypass tube clots.

This usually needs a second operation to clear the blockage. Sometimes the arteries further down on one or both legs cannot take the extra flow of blood. The next steps to deal with this will be discussed with you. The worst case scenario is where it has not been possible to restore satisfactory blood supply to the leg in which case you may need an amputation (removal of the diseased part of the leg).

Wound infection is sometimes seen. This settles down with antibiotics in a week or two. It is much more serious if the infection spreads into your bloodstream or if you have a plastic bypass tube that gets infected. If this is the case you will need antibiotics for much longer and it may be that the plastic bypass tube has to be removed to allow the infection to clear This usually settles down with time, but may need to be drained. This is done by drawing it out with a syringe, or if there's a large amount of fluid, you may need to undergo another operation..The wound sometimes gapes and is slow to heal. This gradually settles down.

Aches and twinges may be felt in the wound for up to six months. Occasionally there are numb patches in the skin around the wound which get better after two to three months. The leg may be swollen for one to two months. This gradually gets better. Late clotting of the graft can occur. You will be given treatment to prevent it and advice to avoid long car and plane journeys without hourly exercise. The overall results of this operation are very good. If the bypass tube is a vein. it stays open in 75% of cases five years after the operation. If the bypass tube is made of plastic it stays open in 55% of cases five years after the operation and patients enjoy a good quality of life.

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