Femoral Artery Percutaneous Transluminal Angioplasty

Femoral Popliteal Bypass Surgery

(Femoropopliteal Bypass-Open, PTA, Balloon Angioplasty)

Procedure overview

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 severe blockage due to plaque in the femoral artery. 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).

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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) 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.

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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 or 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 or 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 or 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

What surgical treatments are used for 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.

Why are femoral bypass surgeries done?

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 doctor will decide the best treatment of your PAD based on your individual circumstances.

There may be other reasons for your doctor to recommend femoral popliteal bypass surgery or PTA.

Risks of the procedure

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 doctor.

There may be other risks depending on your specific medical condition. Be sure to discuss any concerns with your doctor prior to the procedure.

Before the procedure

• Your doctor 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 doctor 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 doctor 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 health care provider.

• Notify your doctor if you are sensitive to or are allergic to any medications, latex, iodine, tape, contrast dyes, and anesthetic agents (local or general).

• Notify your doctor of all medications (prescribed and over-the-counter) and herbal supplements that you are taking.

• Notify your doctor 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 doctor if you have a pacemaker.

• Based on your medical condition, your doctor may request other specific preparation.

During the procedure

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 doctor's practices.

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Generally, femoral popliteal bypass surgery follows this process:

1. You will be asked to remove any jewelry or other objects that may interfere with the procedure.

2. You will be asked to remove your clothing and will be given a gown to wear.

3. 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.

4. You will be positioned on the operating table, lying on your back.

5. 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.

6. 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.

7. Under local anesthesia, you will receive oxygen through a nasal cannula, a tube that fits in your nose.

8. 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.

9. A catheter will be inserted into your bladder to drain urine.

10. You will be given a dose of antibiotics through your IV to help prevent infection.

11. The skin over the surgical site will be cleansed with an antiseptic solution.

12. The doctor 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 doctor will determine whether to use a prosthetic graft or a vein from the leg to bypass the diseased artery.

13. Once the doctor 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.

14. You may receive blood pressure medication through your IV during and after the procedure to keep your blood pressure within a certain range.

15. The incision will be sutured together. A sterile bandage or dressing will be applied.

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Generally, a PTA of the femoral artery procedure follows this process:

1. You will be asked to remove any jewelry or other objects that may interfere with the procedure.

2. You will be asked to remove clothing and will be given a gown to wear.

3. You will be asked to empty your bladder prior to the procedure.

4. 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.

5. You will be placed in a supine (on your back) position on the procedure table.

6. 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.

7. 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.

8. 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.

9. 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.

10. 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.

11. A special catheter or guidewire will be inserted into the femoral artery and advanced to the site of the blockage.

12. 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.

13. The doctor 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.

14. The doctor 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.

15. Once it has been determined that the artery is opened sufficiently, the angioplasty catheter will be removed.

16. The insertion site may be closed with a closure device that uses collagen to seal the opening in the artery or with sutures. Your doctor will determine which method is appropriate for your condition.

17. A sterile dressing or bandage will be applied.

After the procedure

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 doctor.

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 doctor determines that you are ready, you will be moved from the ICU to a postsurgical 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 doctor.

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 doctor.

Once you are home, it will be important to keep the surgical area clean and dry. Your doctor will give you specific bathing instructions.

You may be advised not to participate in any strenuous activities. Your doctor will instruct you about when you can return to work and resume normal activities.

Your doctor may want you to continue on specific medications, such as aspirin or clopidogrel (Plavix), after the procedure.

Your doctor may perform ultrasound examination(s) on your leg after surgery to monitor the new graft.

Notify your doctor 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 or pressure, nausea and/or vomiting, profuse sweating, dizziness, and/or fainting

Your doctor may give you additional or alternate instructions after the procedure, depending on your particular situation.

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 doctor.

If your doctor 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 doctor will give you specific bathing instructions.

You may be advised not to participate in any strenuous activities. Your doctor will instruct you about when you can return to work and resume normal activities.

Notify your doctor 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 doctor may give you additional or alternate instructions after the procedure, depending on your particular situation.