Consent: Lower Limb Bypass

Original Author: Ollie Jones
Last Updated: February 14, 2019
Revisions: 5

This article is for educational purposes only. It should not be used as a template for consenting patients. The person obtaining consent should have clear knowledge of the procedure and the potential risks and complications. Always refer to your local or national guidelines, and the applicable and appropriate law in your jurisdiction governing patient consent.

Overview of Procedure

Any lower limb bypass graft involves dissection of the artery above the occlusion/stenosis, dissection of the artery beyond the disease, and tunneling of a graft between the two sites.

Typical procedures are from the common femoral artery to the above or below knee popliteal, or to the anterior tibial, posterior tibial or peroneal artery. Alternatively, popliteal to pedal bypasses are occasionally done but less common (distal anastomosis to the dorsalis pedis or posterior tibial in the foot).

There are 3 choices of bypass grafts to use. Any bypass below the knee should ideally be undertaken using the patient’s own vein (typically the long saphenous), harvested from the patient at the time of surgery. If this is not available then either a biosynthetic graft can be used (typically in cases where the infection risk is high), or a prosthetic graft is used.

Complications

Intraoperative

Complication Description of Complication Potential Ways to Reduce Risk
Haemorrhage This can occur due to damage to either the artery or vein and may require blood transfusion(s).
Injury to surrounding structures including femoral nerve or vein The femoral artery lies between the femoral nerve and femoral vein. Either of these can be damaged during the dissection if not careful. Similarly this can occur at any level of dissection. Dissect using a standard approach with identification of the inguinal ligament primarily, then approach the artery proximally
Anaesthetic risks Includes damage to the teeth, throat and larynx, reaction to medications, nausea and vomiting, cardiovascular and respiratory complications. Forms a part of the anaesthetist assessment before the operation

Early

Complication Description of Complication Potential Ways to Reduce Risk
Pain The patient will most likely have an epidural anaesthetic to minimise this or use of local anaesthesia during the procedure.
Bleeding There is a small chance of bleeding and bruising in the wounds post-surgery.
Infection Superficial wound infection is possible, and most common in the groin, however graft infection if occurs is a major complication requiring life-long antibiotics and graft excision if possible. Peri-operative antibiotics will reduce the risk of wound and graft infections
Scarring A longitudinal or transverse incisions will result in a scar, which may form a keloid scar, particular in high risk ethnicities. Vein harvest requires extensive incisions.
Seroma A swelling of lymphatic fluid may occur particularly in the groin due to disruption of the lymph nodes and channels. Careful dissection of the lymphatic nodes and channels with ligation will minimise this risk.
Blood clots DVTs and PEs are a possibility in any operation. The risk is increased in patients with a raised BMI, on the pill, recent flights, previous DVT, pregnancy, smokers, cancer and prolonged bed rest. The patient will be given anti-embolism stocking and low molecular weight heparin to minimise this risk as deemed appropriate.
Compartment syndrome Compartment syndrome may occur in patients with prolonged clamp times or in the acute setting. Patients with a long history of peripheral vascular disease are preconditioned for ischaemia so it is less likely in this patient group. Minimise clamp times
Stroke, MI, kidney failure, death Although small, this is always a risk in any major surgery

Late

Complication Description of Complication Potential Ways to Reduce Risk
Hernia Any groin incision can cause a hernia if there is damage to the inguinal ligament or extensive lifting of the ligament during the procedure.
Graft occlusion A kink or narrowing in the graft can lead to occlusion and acute limb ischaemia, requiring thrombolysis, embolectomy, or placement of a new graft, however this is uncommon in these types of bypass surgery.
Reintervention The reintervention rate for bypass grafts increases the more distal they become.

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