Femoral
Popliteal Bypass Surgery / Percutaneous Transluminal
Angioplasty of the Femoral Arteries
(Femoropopliteal
Bypass-Open, PTA, Balloon Angioplasty)
What
are femoral popliteal bypass surgery and percutaneous
transluminal angioplasty of the femoral arteries?
Femoral
popliteal (also called femoropopliteal) bypass
surgery is a surgical procedure that may be used
to treat femoral artery disease. A newer, minimally-invasive
procedure is percutaneous transluminal angioplasty
(PTA) of the femoral arteries.
The
femoral and popliteal arteries are located in
the legs. Their function is to supply oxygen-rich
blood and nutrients to the legs. Femoral and popliteal
arteries are called peripheral arteries because
of their location away from the center of the
body. Disease of the arteries of the limbs (particularly
the legs and feet) is referred to as peripheral
arterial disease (PAD).
What
is peripheral arterial disease?
Peripheral
arterial disease (PAD) is generally associated
with blocked arteries of the legs. The blockage
most often is the result of a chronic buildup
of hard fatty material (atherosclerosis or hardening
of the arteries) into the inside lining of the
arterial wall of the legs. This ultimately narrows
and blocks the flow of blood which carries oxygen
and nutrients to the limb. The femoral and popliteal
arteries are the major arterial blood supply to
the lower extremities and are a common location
for atherosclerotic disease to develop.
The
presence of atherosclerosis in the leg arteries
is a strong indicator that there is also atherosclerosis
in the arteries of the heart and brain, because
atherosclerosis is a widespread disease of the
arteries. Atherosclerosis of the leg arteries
may cause a blockage, obstructing blood flow,
and potentially result in pain in the leg(s),
ulcers or wounds that do not heal, and/or the
need for amputation (surgical removal) of a foot
or leg. Therefore, PAD has two major complications
associated with its presence: limb complications
(nonhealing wounds, ulcers, gangrene, loss of
a limb) and risk for stroke and/or heart attack.
Peripheral
arterial disease caused by atherosclerosis may
be present with symptoms or without symptoms.
The presence of symptoms may depend on the degree
to which blood flow to the leg muscles has been
decreased. Symptoms may range from mild to moderate
to severe.
The
most common symptom of peripheral arterial disease
is called intermittent claudication. Claudication
refers to limping because of pain in the thigh,
calf, and/or buttocks that occurs when walking.
The pain or discomfort of claudication starts
with walking or exercise and stops with rest.
Walking or exercise increases the demand for oxygen
and nutrients needed for the leg muscles to do
work. Decreased blood flow through the affected
artery of the leg(s) due to narrowing or occlusion
(blockage) decreases the amount of oxygen and
nutrients to the muscles and may result in pain.
This symptom is reproducible (the same exercise,
at the same pace, and the same distance, will
reproduce the same symptom), which is helpful
in diagnosing the condition.
Just
as chest pain or angina of the heart can signal
a heart attack, intermittent claudication may
be considered as "angina of the legs" and may
indicate lack of blood flow to the legs. Other
symptoms of peripheral arterial disease may include,
but are not limited to, the following:
- cool/cold feet to touch
- pain in the legs while
lying flat and relieved by a sitting position
- loss of pulses in legs
or feet
- pale color when legs
are raised up
- dependent rubor (redness
when legs are in a dependent [hanging down]
position)
- shiny skin
- loss of hair on feet
- thickened toenail (may
have fungal infections)
- nonhealing wound or
ulcer
- gangrene
- loss of muscle or fatty
tissue
The
most severe symptom of peripheral arterial disease
caused by atherosclerosis is called critical limb
ischemia (lack of oxygen to the limb/leg at rest).
Critical limb ischemia (CLI) is defined as pain
in the leg(s) while at rest, or "rest pain." CLI
is also associated with the breakdown of tissues
(muscle/skin) in the form of ulcers or gangrene
in the limb, which may occur because blood flow
to the limb is so decreased that the basic needs
of the limb for oxygen and nutrients are not being
met. Critical limb ischemia may include some or
all of the symptoms of peripheral arterial disease
as well.
Because
peripheral arterial disease is associated with
the two other major atherosclerotic conditions,
coronary artery disease (heart disease) and cerebrovascular
disease (stroke), treatment may range from management
of risk factors to surgical procedures. The same
risk factors that may contribute to a heart attack or
stroke are the same for peripheral arterial disease.
These include, but are not limited to, the following:
- smoking (tobacco)
- diabetes
- hypertension (high
blood pressure)
- hyperlipidemia (high
blood cholesterol)
- family history of atherosclerosis
Surgical
treatment of peripheral arterial disease of the
femoral arteries:
There
are two procedures used to treat PAD of the femoral
arteries. The standard surgical procedure is femoral
popliteal bypass surgery (fem-pop bypass), while
a newer minimally invasive endovascular intervention
is called percutaneous transluminal angioplasty
(PTA) of the femoral artery.
- femoral popliteal
bypass
Femoral popliteal bypass is the surgical opening
of the upper leg to directly visualize the femoral
artery. It is performed to bypass the blocked
portion of the artery using a piece of another
blood vessel. Blood vessels, or vein grafts,
used for the bypass procedure may be pieces
of a vein taken from the legs. One end of the
vein graft is attached above the blockage and
the other end is attached below the blockage,
rerouting blood flow around the blockage through
the new graft to reach the muscle. In some situations,
a prosthetic (made of artificial material) graft
may be used for the bypass graft, rather than
a vein graft.
- percutaneous transluminal
angioplasty (PTA) of the femoral arteries
Percutaneous transluminal angioplasty is a minimally
invasive (without a large incision) procedure
used to open the blocked or narrowed femoral
artery and to restore arterial blood flow to
the lower leg without open vascular surgery.
A special catheter (long hollow tube) is inserted
into the femoral artery. The catheter has a
tiny balloon at its tip. The balloon is inflated
once the catheter has been placed into the narrowed
area of the artery. The inflation of the balloon
compresses the fatty tissue in the artery and
makes a larger opening inside the artery for
improved blood flow. A stent (a tiny, expandable
metal coil) may be inserted into the newly-opened
area of the artery to help keep the artery from
narrowing or closing again.
Reasons
a femoral popliteal bypass surgery or PTA of the
femoral artery may be performed include, but are
not limited to, the following:
- medical management
that has not improved symptoms, or worsening
of symptoms despite medical management
- severe disability (intermittent
claudication that causes interference with lifestyle
and/or ability to work)
- nonhealing wounds
- infection or gangrene
- ischemic rest pain
(lack of oxygen and nutrients to the leg resulting
in pain at rest)
- danger of losing the
limb due to decreased blood flow
Not
all peripheral arterial disease can be treated
with PTA. Your physician will decide the best
treatment of your PAD based on your individual
circumstances.
There
may be other reasons for your physician to recommend
femoral popliteal bypass surgery or PTA.
As with
any surgical procedure, complications can occur.
Some possible complications may include, but are
not limited to, the following:
- myocardial infarction
(heart attack)
- cardiac arrhythmias
(irregular heart beats)
- hemorrhage (bleeding)
- wound infection
- leg edema (swelling
of the leg)
- thrombosis (clot in
the leg)
- pulmonary edema (fluid
in the lungs)
- bleeding at the catheter
insertion site (usually the groin) after PTA
procedure
- blood clot or damage
to the blood vessel at the insertion site (PTA)
- restenosis (blockage
in the blood vessels after PTA procedure)
- nerve injury
- graft occlusion (blockage
in the graft used in bypass surgery)
Patients
who are allergic to or sensitive to medications,
contrast dyes, iodine, shellfish, or latex should
notify their physician.
There
may be other risks depending upon your specific
medical condition. Be sure to discuss any concerns
with your physician prior to the procedure.
- Your physician will
explain the procedure to you and offer you the
opportunity to ask any questions that you might
have about the procedure.
- You will be asked to
sign a consent form that gives permission to
do the procedure. Read the form carefully and
ask questions if something is not clear.
- In addition to a complete
medical history, your physician may perform
a physical examination to ensure you are in
good health before you undergo the procedure.
You may also undergo blood tests and other diagnostic
tests.
- Your physician may
recommend taking an aspirin prior to the procedure.
- You will be asked to
fast for eight hours before the procedure, generally
after midnight.
- If you are pregnant
or suspect that you are pregnant, you should
notify your physician.
- Notify your physician
if you are sensitive to or are allergic to any
medications, latex, iodine, tape, contrast dyes,
and anesthetic agents (local or general).
- Notify your physician
of all medications (prescribed and over-the-counter)
and herbal supplements that you are taking.
- Notify your physician
if you have a history of bleeding disorders
or if you are taking any anticoagulant (blood-thinning)
medications, aspirin, or other medications that
affect blood clotting. It may be necessary for
you to stop these medications prior to the procedure.
- If you smoke, you should
stop smoking as soon as possible prior to the
procedure, in order to improve your chances
for a successful recovery from surgery and to
improve your overall health status.
- You may receive a sedative
prior to the procedure to help you relax.
- The areas around the
surgical site may be shaved.
- Notify your physician
if you have a pacemaker.
- Based upon your medical
condition, your physician may request other
specific preparation.
Femoral
popliteal bypass surgery and percutaneous transluminal
angioplasty of the femoral artery require
a stay in the hospital. Procedures may vary depending
on your condition and your physician's practices.
Femoral
popliteal bypass surgery:
Generally,
femoral popliteal bypass surgery follows this
process:
- You will be asked to
remove any jewelry or other objects that may
interfere with the procedure.
- You will be asked to
remove your clothing and will be given a gown
to wear.
- An intravenous (IV)
line will be started in your arm or hand. Additional
catheters may be inserted in your neck and wrist
to monitor the status of your heart and blood
pressure, as well as for obtaining blood samples.
An alternate site for the additional catheters
includes the subclavian (under the collarbone)
area.
- You will be positioned
on the operating table, lying on your back.
- The anesthesiologist
will continuously monitor your heart rate, blood
pressure, breathing, and blood oxygen level
during the surgery. You will be connected to
an ECG monitor that records the electrical activity
of the heart and monitors the heart during the
procedure using small, adhesive electrodes.
- A femoral popliteal
bypass may be performed under local anesthesia.
You will not feel the area to be operated on.
You will receive a sedative medication in your
IV before the procedure to help you relax. However,
you will likely remain awake, but sleepy, during
the procedure.
- Under local anesthesia,
you will receive oxygen through a nasal cannula,
a tube that fits in your nose.
- Femoral popliteal bypass
may also be performed under general anesthesia
(you will be asleep). Once you are sedated,
a breathing tube will be inserted through your
throat into your lungs and you will be connected
to a ventilator, which will breathe for you
during the surgery.
- A catheter will be
inserted into your bladder to drain urine.
- You will be given a
dose of antibiotics through your IV to help
prevent infection.
- The skin over the surgical
site will be cleansed with an antiseptic solution.
- The physician will
make an incision (cut) in the leg. The site
of the incision will depend on the section of
the arteries to be bypassed. The physician will
determine whether to use a prosthetic graft
or a vein from the leg to bypass the diseased
artery.
- Once the physician
has attached the graft onto the diseased artery,
an arteriogram may be performed to confirm that
blood flow has been restored to the leg through
the new bypass graft.
- You may receive blood
pressure medication through your IV during and
after the procedure to keep your blood pressure
within a certain range.
- The incision will be
sutured together. A sterile bandage/dressing
will be applied.
Percutaneous
transluminal angioplasty (PTA) of the femoral
artery:
Generally,
a PTA of the femoral artery procedure follows
this process:
- You will be asked to
remove any jewelry or other objects that may
interfere with the procedure.
- You will be asked to
remove clothing and will be given a gown to
wear.
- You will be asked to
empty your bladder prior to the procedure.
- An intravenous (IV)
line will be started in your hand or arm prior
to the procedure for injection of medication
and to administer IV fluids, if needed.
- You will be placed
in a supine (on your back) position on the procedure
table.
- You will be connected
to an ECG monitor that records the electrical
activity of the heart and monitors the heart
during the procedure using small, adhesive electrodes.
Your vital signs (heart rate, blood pressure,
breathing rate, and oxygenation level) will
be monitored during the procedure.
- You will receive a
sedative medication in your IV before the procedure
to help you relax. However, you will likely
remain awake, but sleepy, during the procedure.
- Your pulses below the
insertion site will be checked and marked so
that the circulation to the limb below the site
can be checked after the procedure.
- A local anesthetic
will be injected into the skin at the insertion
site. You may feel some stinging at the site
for a few seconds after the local anesthetic
is injected.
- Once the local anesthetic
has taken effect, a sheath, or introducer, will
be inserted into the blood vessel. This is a
plastic tube through which the catheter will
be inserted into the femoral artery.
- A special catheter/guidewire
will be inserted into the femoral artery and
advanced to the site of the blockage.
- The proper position
of the catheter may be confirmed by injecting
a small amount of contrast dye into the artery,
which may then be seen on a TV-like monitor.
- The physician will
insert an angioplasty catheter and advance it
to the location of the blockage. A balloon at
the tip of the catheter will be inflated to
open the artery.
- The physician may inflate
and deflate the balloon several times to open
the artery. In some situations, a stent (a tiny,
expandable metal coil) may be inserted into
the newly-opened area of the artery to help
keep the artery from narrowing or closing again.
- Once it has been determined
that the artery is opened sufficiently, the
angioplasty catheter will be removed.
- The insertion site
may be closed with a closure device that uses
collagen to seal the opening in the artery or
with sutures. Your physician will determine
which method is appropriate for your condition.
- A sterile dressing/bandage
will be applied.
In
the hospital - femoral popliteal bypass:
After
the procedure you will be taken to the recovery
room for observation. Once your blood pressure,
pulse, and breathing are stable and you are alert,
you may be taken to the intensive care unit (ICU)
or your hospital room.
Your
pulses below the surgical site will be checked
frequently to assist in monitoring blood flow
to the limb. Your leg will also be monitored for
color (pale or pink), warmth (coolness), sensations
of pain, and movement.
The
surgical incision may be tender or sore for several
days after the procedure. Take a pain reliever
for soreness as recommended by your physician.
You
may be on special IV medications to help
your blood pressure and your heart, and to control
any problems with bleeding. As your condition
stabilizes, these medications will be gradually
decreased and discontinued as your condition allows.
Your
diet will be advanced to solid foods as tolerated.
When
your physician determines that you are ready,
you will be moved from the ICU to a post-surgical
nursing unit. Your recovery will continue to progress.
Your activity will be gradually increased as you
get out of bed and walk around for longer periods
of time.
Arrangements
will be made for a follow-up visit with your physician.
In
the hospital - PTA of the femoral artery:
After
the procedure you will be taken to the recovery
room for observation. Once your blood pressure,
pulse, and breathing are stable and you are alert,
you may be taken to the intensive care unit (ICU)
or your hospital room.
You
should immediately inform your nurse if you feel
any chest pain or tightness, or any other pain,
as well as any feelings of warmth, bleeding, or
pain at the insertion site in your leg or arm.
The
nurse will assist you the first time you get up.
You should move slowly when getting up from the
bed to avoid any dizziness from the long period
of bed rest.
You
may be given pain medication for pain or discomfort
related to the insertion site or having to lie
flat and still for a prolonged period.
Your
diet will be advanced to solid foods as tolerated.
Your
hospital stay will depend on your condition and
the results of your procedure. You will receive
detailed instructions for your discharge and recovery
period.
Arrangements
will be made for a follow-up visit with your physician.
At
home - femoral popliteal bypass:
Once
you are home, it will be important to keep the
surgical area clean and dry. Your physician will
give you specific bathing instructions.
You
may be advised not to participate in any strenuous
activities. Your physician will instruct you about
when you can return to work and resume normal
activities.
Your
physician may want you to continue on specific
medications, such as aspirin or clopidogrel (Plavix®),
after the procedure.
Your
physician may perform ultrasound examination(s)
on your leg after surgery to monitor the new graft.
Notify
your physician to report any of the following:
- fever and/or chills
- increased pain, redness,
swelling, or bleeding or other drainage from
the leg incision
- coolness, numbness
and/or tingling, or other changes in the affected
extremity
- chest pain/pressure,
nausea and/or vomiting, profuse sweating, dizziness,
and/or fainting
Your
physician may give you additional or alternate
instructions after the procedure, depending on
your particular situation.
At
home - PTA of the femoral artery:
Once
at home, you should monitor the insertion site
for bleeding, unusual pain, swelling, and abnormal
discoloration or temperature change at or near
the insertion site. A small bruise is normal.
If you notice a constant or large amount of blood
at the site that cannot be contained with a small
dressing, notify your physician.
If your
physician used a closure device for your insertion
site, you will be given specific information regarding
the type of closure device that was used and how
to take care of the insertion site. There will
be a small knot, or lump, under the skin, where
the insertion site was. This is normal. The knot
should gradually disappear over a few weeks.
It will
be important to keep the insertion site clean
and dry. Your physician will give you specific
bathing instructions.
You
may be advised not to participate in any strenuous
activities. Your physician will instruct you about
when you can return to work and resume normal
activities.
Notify
your physician to report any of the following:
- fever and/or chills
- increased pain, redness,
swelling, or bleeding or other drainage from
the insertion site
- coolness, numbness
and/or tingling, or other changes in the affected
extremity
- chest pain/pressure,
nausea and/or vomiting, profuse sweating, dizziness,
and/or fainting
Your
physician may give you additional or alternate
instructions after the procedure, depending on
your particular situation.
The
content provided here is for informational purposes
only, and was not designed to diagnose or treat
a health problem or disease, or replace the professional
medical advice you receive from your physician.
Please consult your physician with any questions
or concerns you may have regarding your condition.
This
page contains links to other Web sites with information
about this procedure and related health conditions.
We hope you find these sites helpful, but please
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