Aorto-bi-femoral bypass is a major operation performed under general anaesthesia (with you asleep). The first part of your operation involves administering the anaesthetic. A tube will be placed into your air pipe once you have been anaesthetised and connected to a mechanical ventilator which will breathe for you during the operation. Additionally, you will have a tube (catheter) inserted into your bladder to drain your urine. This facilitates accurate assessment of your hydration status during and immediately after the operation. The anaesthetist will furthermore insert a small tube into an artery in your wrist to enable accurate measurement of your blood pressure during your operation. In order to minimise pain after the operation as much as possible, the anaesthetist may place a catheter in the epidural space of your spinal cord - an "epidural". This catheter will be connected to a pump for continuous administration of pain-relieving drugs during the first 4-5 days after surgery that numb the nerves supplying the area of the abdominal incision. In case of contra-indications for epidural catheter placement, your surgeon may opt to place a catheter for pain relief in your abdominal wall at the end of the procedure. Once the necessary monitoring equipment has been connected your surgeon will start the operation. Circulation Clinic undertakes all open aortic surgical procedures as a joint case with two of our experienced consultants operating together. This reduces the time taken to perform the operation and thereby the time you are under general anaesthesia. We strongly believe this improves our clients' outcomes and reduces the risk of a variety of potential complications including heart attacks, kidney failure, respiratory complications and infection rates. Through a midline laparotomy (occasionally a transverse incision may be used) the surgeons will gain access to your abdominal cavity. After a brief inspection of the abdominal cavity (to ensure that nothing untoward is found that was not evident on pre-operative investigations/imaging), they will proceed to expose the aorta and both common iliac arteries. Depending on the extent of the disease they may have to expose the renal arteries proximally. Once adequate exposure has been achieved an aortic clamp will be placed proximally. All efforts are taken to place this clamp below the renal arteries, so that the kidneys remain perfused during the operation; however in selected extensive cases your surgeons may deem it necessary to temporarily clamp the aorta above the renal arteries thereby temporarily, interrupting the blood flow to the kidneys. The aorta is then opened. Often the aorta has significant disease even above the area of blockage; your surgeons may need to clear this disease (endarterectomy) to create a suitable site to anastomose (join) the synthetic graft to. The waist of a trouser shaped graft is then anastomosed to the aortic opening with non-absorbable sutures. The limbs of the trouser graft are then tunnelled through the pelvis into the groin. The femoral arteries are exposed through vertical groin incisions in each groin. The femoral arteries are clamped and then opened (arteriotomy). In our experience, femoral endarterectomy is almost always required to improve the patency of the femoral arteries and allow for adequate outflow for the aortic graft limbs. Once the endarterectomy has been completed a limb of the trouser graft is then anastomosed to the femoral artery creating the aorto-bi-femoral bypass. Following the bypass reconstruction all wounds are repaired in layers with stitches. If you have not been given an epidural catheter, your surgeon will now place catheters in your abdominal wall for post-operative pain relief. Drains may be inserted into the groin wounds to drain any excess fluid that may accumulate in the immediate post-operative period. After the operation you will be transported to Intensive Care Unit (ICU). Depending on how well you are at the end of the operation, the ICU team will try to wake you up as soon as possible. However, they may deem it necessary to keep you sedated for one day (or longer) following the operation. One or two days after the operation you should be well enough to be transferred to the ward where you will stay 4-5 more days until you are fit for discharge.