Patient Information – Consent for Bypass Grafting
The intended benefits: a bypass may be done for different reasons to improve the circulation to one or both legs or feet; it can help reduce pain or risk of amputation or help ulcers to heal and can stop gangrene spreading. It may also improve your walking
Alternative treatments: some patients continue with just supportive treatment, such as painkillers or dressings, especially if the leg is not too bad. However, pain, infection, blood poisoning and death continue to be serious risks if there are ulcers or gangrene. Circulation in some, but not all patients, can be successfully improved with balloons (angioplasty) or stents and this may be tried first if feasible, but surgical bypass or amputations are often the alternatives when this fails.
Serious or frequently occurring risks: bypass grafts are not always durable and can block or narrow at any time afterwards; around one in ten fail within the first month and another one in ten within a year. We can sometimes get them going again be re-operating. Overall, around five to seven in ten are still working after two years and half after five years. When grafts stop working, amputation is commonly needed. Around one in ten patients experience a problem with wound healing which may require further surgery or prolonged dressings. Bleeding from the wound is rare because we take great care to avoid it and often use a drain in the wound but it may require a return to the operating theatre. Around one in ten patients develop a wound infection and need antibiotics. Around one in ten patients develop a blood clot in veins (DVT). This can occur in either leg and is treated by injections (enoxaparin or Clexane) and then tablets (Warfarin) to reduce the tendency of blood to clot (often termed “thinning the blood”); DVT usually resolves but occasionally may leave a chronically swollen leg or clot may pass to the lungs which can be dangerous( pulmonary embolism or PE, one in ten DVTS do this). Because patients are often unwell when bypass is needed, there are more general risks due to the stress of surgery and anaesthetic. These include heart attack or heart failure, chest infection, pulmonary embolism, stroke and kidney failure. Overall, death occurs in around 3% when the operation is planned ahead as a “routine case” but in urgent or emergency situations rises to around 10% despite all the supportive care that we can give. Unwell patients spending long periods in bed are also prone to developing bed sores, especially on the heels and bottom. These still occur despite good nursing care and special beds and mattresses. Modern anaesthetics are generally very safe and you will have the opportunity to discuss this in detail with your Anaesthetist. In most patients, sedatives plus injections in your back (epidural or spinal anaesthetic) to numb the lower half of your body (epidural and/or spinal anesthetic)are preferable as this avoids any complications from general anaesthesia.
Commoner side effects of an epidural or spinal anaesthesia include:
- Inability to pass urine: bladder function will return to normal after the epidural wears off
- Low blood pressure
- Itching, feeling sick and vomiting or headache
- Backache is common after surgery and not always related to the epidural
- Inadequate pain relief- other methods of pain relief will be used if the epidural fails.
Uncommon complications include slow breathing and epidural catheter infection. Rare or very rare complications include fits, permanent disabling nerve damage, epidural infection, epidural blood clot and cardiac arrest.
Commoner side effects of a general anaesthetic(1 in 10-100) include: pain during drug injection, aches, pain and backache. Uncommon problems (1 in 1000) include: bladder problems, muscle pains or worsening of an existing medical condition. Rare complications (1 in 10,000-100,000) include: bleeding, nerve damage, serious allergy to drugs, awareness during surgery, equipment failure and death due solely to the anaesthetic.
Any extra procedures which may become necessary during the operation:
- Blood transfusion is rarely needed unless you are already anaemic but transfusions can result in severe allergic reactions or infections despite careful screening of the blood for you
- Photographs and images X-rays are a usual part of this operation but if we want images for teaching or research purposes, we would always ask your special permission
- Other procedures, except for those listed above, are not often required during this operation unless planned in advance, the problems listed above can lead to additional procedures as described.