bypass

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In medicine, bypass is surgically created bypassing of narrowed blood vessels. Bypasses are mainly applied to the heart, but also to other blood vessels when the diseased vessels are no longer sufficient for the blood supply. Here you can read when and how heart bypass surgery is performed and what to watch out for afterwards.

What is a bypass?

Bypass means "bypass". In medical terms, this means bypassing blood vessels that are restricted in their function. In the case of certain diseases such as intermittent claudication (peripheral arterial occlusive disease in the leg arteries), artificial vascular bypassing may be necessary as well as narrowing of vessels in the heart (coronary heart disease).

Cardiac bypass improves the oxygen supply to the heart muscle or restores it completely. The bypass is sewn behind narrowed or closed vessel sections and thus bypasses them. If doctors use vessels from the arm or leg for this, one end is sewn to the main artery (aorta) and the other behind the coronary artery. Therefore this bypass is called aortocoronary bypass, or ACB for short.

When do you perform bypass surgery?

There are several reasons for bypassing. In the heart they are often necessary when

• During a cardiac catheter examination, the widening or reopening of a coronary artery was unsuccessful
• one or two coronary vessels are affected and the left coronary artery (LAD) is narrowed or closed at its base, a so-called main trunk stenosis
• all three main branches of the coronary arteries are affected at the same time ("three-vessel disease")
• there are multiple narrowings across long arteries and the patient is diabetic
• Several coronary arteries are affected and the pumping function of the left ventricle is restricted due to the lack of oxygen and nutrients
• when the anterior artery between the two chambers of the heart (RIVA, starts from the left coronary artery) is severely narrowed at its beginning

But there are also some reasons that speak against bypass surgery. One of these contraindications is when life expectancy is severely reduced due to other diseases. In any case, serious concomitant diseases may prevent the procedure.

What do you do in a bypass operation?

The procedure takes place under general anesthesia. Often the patient's body is cooled a little before the operation. This slows down metabolic processes and reduces the need for oxygen during bypass surgery. The duration and exact procedure of the operation are not always the same, but the procedure takes about three to four hours on average.

In classic bypass surgery, the sternum is split over its entire length (median longitudinal sternotomy) in order to gain access to the heart and the surrounding structures. After the pericardium has been opened, the large vessels (aorta / large veins) are connected to the heart-lung machine. This now takes over the oxygen supply of the body and the removal of carbon dioxide. The heart is immobilized with a special, cold electrolyte solution (cardio-care solution) for the next steps so that the surgeon can begin to place the actual bypass.

Arteries and veins (usually the great saphenous vein, alternatively parva) can be used as bypass material. However, we now know that veins are more quickly affected by renewed constrictions or occlusions than arteries. The chest wall artery (arteria thoracica interna) is most frequently used, as its anatomical position in relation to the heart is favorable and the outlet from the subclavian artery can remain unchanged. In this case, only the heart-side connection to the coronary vessel needs to be created.

By the way: the internal thoracic artery is also known as the internal mammary artery. Surgeons therefore like to refer to this bypass as IMA bypass (internal mammary artery bypass). Since you usually use the left IMA as a bypass, this bypass is also known as LIMA bypass (L for left).

Less often, an artery of the arm (arteria radialis) is used for the bypass. In this case, the piece of vessel must be sutured to both the aorta and the respective coronary artery (beyond the constriction) so that the desired bypass occurs. In addition, it must be ensured beforehand that blood flow to the hand is guaranteed even without a radial artery (Allen test).

When the bypass is successfully applied, the right atrium and right ventricle are temporarily connected to a pacemaker and the paralyzing electrolyte solution is flushed out. Now the heart can take over the supply of the body again. The heart-lung machine is then no longer necessary after a short time and is again separated from the large blood vessels.

Finally, some suction drains are placed in the chest, which drain blood and wound secretions to the outside in the first few days after the operation. The chest is then closed again. Doctors use wires to hold the bony sternum together.

After the bypass operation, the patient is closely monitored

Close observation of the patient is essential after major operations, including after a bypass operation. Heart, circulation as well as respiration and organ functions are continuously measured, monitored and evaluated in the intensive care unit for at least one day.

Other variants of bypass surgery

In addition to the classic procedure, there are other variants of the bypass operation. The procedure and procedure vary depending on the individual requirements: For example, in suitable patients - for example if only one vessel has to be bypassed - minimally invasive surgical methods (without complete splitting of the sternum) can be considered - for example by means of an incision on the left chest wall (anterolateral mini thoracotomy ). The so-called “Off-Pump Coronary Artery Bypass” is performed without a heart-lung machine, so the heart pumps itself. Bypass operations of this type are often referred to by doctors as MIDCAB technology (“Minimally Invasive Direct Coronary Artery Bypass”).

What are the risks of bypass surgery?

Complications can arise during or after bypass surgery, as with any other major surgery. You are at a higher risk if it is an emergency procedure, if the heart has already been operated on, and if the cardiac output is severely reduced. Over the past few decades, however, the risk of serious complications has steadily decreased. It is also significantly influenced by other illnesses in the patient. These include diseases of the kidneys or lungs, as well as metabolic diseases such as diabetes. The old age of the patient is also considered to be a special risk factor.

The following complications can arise during or after bypass surgery:

• Heart attack during and after the operation (e.g. due to the closure of the bypass)
• Cardiac arrhythmias (but mostly treatable)
• Circulatory weakness due to insufficient heart pumping
• Pericardial tamponade (secondary bleeding into the pericardium, which then mechanically constricts the heart)
• Stroke or other neurological disorders such as confusion
• Post-myocardial infarction syndrome (Dressler syndrome, autoimmune processes trigger, for example, pericarditis, generally possible with a heart attack)

Further possible complications after successful bypass surgery: disorders of wound healing or infections, bleeding and pain. They are more common with some pre-existing conditions (e.g. more wound healing disorders in diabetics). Smokers are more likely to develop pneumonia immediately after surgery than non-smokers. If kidney function was impaired before the bypass operation, artificial blood washing (dialysis) may be necessary temporarily. Blood clots are also a possible consequence of the operation. Overall, one to two percent of patients die during bypass surgery.

What do I have to consider after a bypass operation?

In a normal course, the patient is discharged about seven to ten days after a bypass operation, after which cardiac rehabilitation clinics take over the so-called follow-up treatment (AHB), which lasts three to four weeks. In some cases, the patient is also discharged home and rehabilitation treatment can be carried out on an outpatient basis.

It is very important to avoid risks after bypass surgery. Above all, this includes smoking, excessive alcohol consumption, and foods that are too fatty or too salty. A Mediterranean diet is often recommended. In combination with regular exercise, the risk factor obesity can be reduced, among other things. If the patients also avoid stress, they have laid another cornerstone for the long-term success of bypass surgery.

Bypass OP follow-up care

Long-term medication is usually required after bypass surgery. In particular, the long-term use of platelet aggregation inhibitors is common to prevent new thrombi (blood clots) from forming in the coronary arteries or in the bypass.

In addition to a platelet aggregation inhibitor (e.g. acetylsalicylic acid, ASA for short), the doctor usually prescribes other medications. These can be:

• ACE inhibitors and calcium channel blockers (including treatment for high blood pressure)
• Beta-receptor blockers (e.g. against high blood pressure and arrhythmias)
• Statins (therapy for increased blood lipid levels)
• Nitrates (e.g. as a spray to treat angina attacks if necessary)

Some patients develop a depressive mood some time after the bypass surgery. It is important to talk about the feelings and understand the operation as a new beginning and opportunity. The doctor giving further treatment (often the family doctor) should be informed about this, he will then point out psychotherapeutic options. He can also help you change your lifestyle. On the one hand, this prevents the rapid progression of cardiovascular diseases, and on the other hand, the bypass then lasts longer.

Exercise after bypass surgery

With a complication-free bypass operation, the patient can start early mobilization as early as 24 to 48 hours after the operation. However, restrictions on physical activity can still be expected in the first few weeks. The training should therefore start with gentle exercises.

Patients should avoid supporting, tensile and compressive loads for at least six weeks. This exerts unnecessary pulling forces on the surgical site. Patients should also avoid pressure on the chest in the first few weeks after the procedure. Jerky movements are also unfavorable. If the procedure was performed in a minimally invasive manner, the period of time in which restrictions can be expected can be shorter.

Discuss the start of training after a bypass operation with your doctor in advance.

Depending on their individual well-being and personal resilience, patients should first start with low stress and then gradually increase.

Suitable sports after the bypass

Can you ride a bike after bypass surgery? In principle, all types of sport are possible with a bypass operation. In stressful disciplines, competitive or competitive sports, however, you should discuss your return to work with your doctor in advance.

In order to become active after a bypass operation, gentle endurance sports are initially suitable. These include, for example:

• Walk
• hike
• jog
• Cycling or ergometer training
• swim

In order to achieve a health-promoting effect, bypass patients should exercise about three times a week for 30 minutes each time with moderate exertion. This is not only good for the heart, but also contributes to a healthy weight.

Warning: If you experience breathlessness, sweating, racing heart or chest pain while exercising, you must stop exercising immediately. Talk to a doctor straight away.

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