The heart pumps oxygen-rich blood into the aorta. Arteries branch towards the pelvis and legs, with the femoral artery in the thigh continuing towards the popliteal artery behind the knee and smaller arteries in the lower leg and foot. These branches deliver oxygen and nutrients to muscle, nerves, skin and other tissues. During walking, muscles need more oxygen, so a restricted supply can become noticeable with exertion.

Peripheral arterial disease, often shortened to PAD, usually develops when fatty material builds up in artery walls. This process, atherosclerosis, can narrow or block the channel through which blood passes. Reduced blood supply is called ischaemia. Other arteries can form alternative pathways, but their ability to carry enough blood varies. Disease can occur at several levels, so a scan is needed to map the route rather than assuming that one painful area identifies the blockage.

Veins normally carry blood back towards the heart; arteries carry blood away from it. An arterial bypass uses a graft to carry blood around a diseased artery. Sometimes the graft is made from a vein, but the operation is still an arterial bypass, not treatment of varicose veins or a deep vein clot. Coronary bypass reroutes blood to heart muscle; leg bypass aims to improve blood supply to the leg or foot.

Intermittent claudication is a repeatable ache, cramp or burning when walking that settles after a few minutes of rest. It commonly affects the calf, but the thigh, foot or buttock can be involved. Walking uphill or faster may bring symptoms on sooner. Other conditions can cause leg pain, and some people with PAD have few or no symptoms. Report a change in walking distance or pattern to your clinician.

Chronic limb-threatening ischaemia, often called CLTI or previously critical limb ischaemia, is a more severe pattern of inadequate blood supply. Ischaemic pain in the foot at rest, particularly at night, or an ulcer that does not heal or gangrene can signal tissue at risk. A person may have more than one feature; diabetes-related nerve damage can change the sensation of pain. New rest pain or a non-healing foot wound needs prompt medical assessment and a plan for vascular review, not an exercise-only plan.

Acute limb ischaemia is a sudden reduction in blood flow, for example from a clot forming in a diseased artery or bypass, or a clot travelling from elsewhere. It can occur in someone with or without known PAD. The speed of the change and new coldness, pain, numbness or weakness matter. It is a time-critical emergency even when there has been no previous operation. Use the emergency instructions above.

PAD also signals increased risk of heart attack and stroke. Leg treatment and whole-body cardiovascular protection address related but different goals. A bypass can improve blood flow to a foot while disease elsewhere still needs attention. Tell your team about chest symptoms or stroke signs immediately and call 999 for an emergency.

A clinician asks about walking distance, rest pain, wounds and how symptoms affect daily life. They examine both legs and feet, inspect wounds and check pulses at the groin, behind the knee and in the feet. Other conditions and previous procedures matter. If diabetes has reduced foot sensation, a serious wound may not be as painful as expected.

The ankle brachial pressure index, or ABPI, compares blood pressure at the ankle with pressure at the arm, usually using a Doppler probe. It helps assess circulation but does not by itself map every blockage. NICE says not to rule out PAD in a person with diabetes solely because the ABPI is normal or raised: hardened arteries can give a misleading reading. The team considers the examination and may use other tests.

When revascularisation, restoring blood flow, is being considered, NICE recommends duplex ultrasound first. This uses sound waves to examine arteries and flow. Further imaging may include contrast-enhanced MR angiography or CT angiography if MR is unsuitable. Imaging shows where an artery is narrowed, what inflow is available above the blockage and where a graft or catheter treatment might reach below it.

Ultrasound vein mapping can check whether a suitable vein is available for a graft. Blood tests and an ECG may help assess general health and the planned anaesthetic. Tell the team about kidney disease and previous reactions to contrast if a scan with contrast is proposed. In an emergency the order and timing of tests are adapted to the urgency of the limb.

Treatment for PAD includes lowering the risk of heart attack and stroke as well as addressing leg symptoms. Depending on the individual, this can include an antiplatelet medicine such as clopidogrel, a statin, and treatment of high blood pressure or diabetes. Stopping smoking, eating well and appropriate activity also matter. These measures remain relevant after an intervention because a graft does not remove atherosclerosis throughout the body.

For intermittent claudication, NICE recommends a supervised exercise programme. Its suggested programme involves two hours of supervised exercise a week for three months, with walking to maximal pain under supervision. Ask about local access, what to do during pain, and how the programme fits other health conditions. This is guidance for assessed claudication, not a reason to exercise through new rest pain, a threatened foot or a sudden cold limb.

NICE says naftidrofuryl oxalate can be considered for claudication if supervised exercise has not improved symptoms satisfactorily and the person prefers not to be referred for angioplasty or bypass. Benefit should be reviewed after three to six months and treatment stopped if there is no symptomatic improvement. It is not a substitute for urgent assessment of limb-threatening symptoms.

For CLTI, pain relief, foot and wound care, and treatment of infection may be needed alongside a decision about restoring blood flow. If diabetes is present, a multidisciplinary foot service may be involved. The immediate goal is different from increasing a stable walking distance: the team must assess threatened tissue, infection and the possibility of healing.

Angioplasty treats the artery from inside. A clinician guides a catheter to the narrowing and inflates a small balloon to widen it; a metal mesh stent may sometimes remain in place. It commonly uses a small access site. Bypass is open surgery that creates a separate path around the blockage. Either approach may need later treatment, and suitability depends on the location and length of disease, blood flow beyond it, health and local expertise.

For severe lifestyle-limiting claudication, NICE recommends bypass only when angioplasty has failed or is unsuitable and imaging confirms that bypass is appropriate. NICE recommends angioplasty for claudication only after risk-factor advice and an unsatisfactory response to supervised exercise, with imaging confirming suitability. These recommendations concern stable claudication and should not be applied as a waiting rule for CLTI or acute ischaemia.

For critical limb ischaemia, NICE recommends assessment by a vascular multidisciplinary team before treatment decisions, and offering angioplasty or bypass to people who need revascularisation, taking account of other conditions, disease pattern, available vein and patient preference. A procedure can aim to relieve pain or support wound healing and limb preservation, but successful restoration of flow does not guarantee a wound will heal or remove all need for further treatment.

Sometimes an artery can be treated through another operation, or open and catheter techniques may be combined, depending on anatomy. If restoration of flow is not possible or would not achieve a meaningful goal, the team can discuss pain control, wound care, support and, in some circumstances, amputation. NICE says major amputation for critical limb ischaemia should not be offered until a vascular multidisciplinary team has considered all revascularisation options.

Ask the team to compare the actual options in your case, including doing no procedure now, rather than treating a shorter incision as the whole decision. How quickly does the foot need attention? What chance is there of healing, further procedures or remaining pain? If the condition is urgent, the time available to decide may be short; clinicians should explain why.

The surgeon connects a graft to an artery above and another artery below the blocked section. Blood can then travel through the graft around the obstruction. The original narrowed artery is not necessarily removed. A femoropopliteal bypass connects the femoral region to an artery around the knee; a more distal bypass can reach an artery further down the leg or foot. The exact route depends on the healthy arteries available at either end.

A graft may be made from your own vein, often from the leg and sometimes the arm. The team uses ultrasound to look for suitable vein. NICE recommends using the person’s own vein whenever possible for bypass below the groin in claudication or critical limb ischaemia. If an appropriate vein is unavailable, a synthetic graft may be considered; the choice also depends on the route and the surgeon’s assessment. The vein is being used as a new route for arterial blood.

Taking a vein creates an additional wound, and the operation can leave scars in the groin, thigh, calf, foot or arm depending on the plan. Ask which vein is being considered, whether you have other suitable veins if it is not usable, and what the alternatives would be. Vein and synthetic grafts can narrow or block, so the type of graft affects follow-up as well as the operation.

BEST-CLI enrolled 1,830 adults with CLTI and disease below the groin, selected because specialists considered both surgery and endovascular treatment feasible. In the cohort with a suitable single segment of great saphenous vein, the combined outcome of major limb reintervention, above-ankle amputation or death occurred in 302 of 709 analysed people assigned surgery and 408 of 711 assigned endovascular treatment, with a median follow-up of 2.7 years. This is a combined outcome, not a percentage who had an amputation.

In BEST-CLI’s separate cohort without a suitable single segment of great saphenous vein, the combined outcome did not differ significantly between the groups. The smaller cohort had shorter median follow-up and the confidence interval included potentially meaningful differences; a non-significant result does not prove the approaches are identical. The planned number of participants was not reached because recruitment was difficult, and funding did not allow the planned minimum follow-up in the smaller cohort. Trial patients were judged suitable for both approaches, so these findings cannot be applied to every person with PAD or to uncomplicated claudication.

BASIL-2 asked a narrower question in 345 people with CLTI needing treatment of arteries below the knee, with or without treatment higher in the leg. After at least two years of follow-up, major amputation or death occurred in 108 of 172 assigned a vein-bypass-first strategy and 92 of 173 assigned an endovascular-first strategy. The difference in amputation-free survival favoured endovascular first and was largely driven by deaths, not a simple comparison of amputation alone.

BASIL-2 was open-label, recruited mainly in the UK, and did not reach its planned target number of events. BEST-CLI and BASIL-2 enrolled different populations, used different combined outcomes and compared initial treatment strategies. Their apparently different results are not a universal ranking. Ask whether you resemble either trial population, which arteries need treatment and how the evidence relates to your priorities and local options.

Pre-assessment reviews your health, previous procedures, test results, anaesthetic options and the planned graft. Bring a complete list of prescribed and over-the-counter medicines, vitamins and supplements, and mention allergies. Ask specifically which medicines to continue, pause and restart, especially antiplatelets, anticoagulants and diabetes medicines. Do not change them yourself: instructions depend on why you take them and your bleeding and clotting risks.

Follow your hospital’s instructions on food, drink, arrival and any changes in health before surgery. Discuss smoking-cessation support, mobility aids, wound care, transport and help at home. If a foot wound or infection worsens while you wait, contact the team promptly; follow the emergency instructions for sudden changes or suspected gangrene. Emergency procedures allow less time for preparation and the plan is adapted accordingly.

Consent is a discussion, not simply a signature. Ask the surgeon and anaesthetist to describe the intended benefit, your personal risks and reasonable alternatives, and whether additional treatment such as removal of dead tissue might be needed. You can ask for written information or an interpreter and include someone you trust where circumstances allow.

A leg bypass may be performed under general anaesthetic, so you are asleep, or an epidural or other regional technique may be used, sometimes with sedation. The choice depends on your operation and health. A cannula can deliver medicines and fluids, and a bladder catheter or other monitoring may be used. Your anaesthetist can explain the planned approach and pain relief.

The surgeon makes incisions to reach an artery above and a suitable artery below the blockage. If using a vein, the team prepares it; otherwise a synthetic tube may be used. The graft is stitched to the arteries to provide another route for blood. Your scars and the length of the operation depend on the intended route and what the team finds. Existing infected or dead tissue may need separate treatment, sometimes including removal of affected tissue.

After theatre, staff monitor your breathing, circulation, wound and leg. Some people need closer monitoring in a high-dependency area. Pain relief, help to move, fluids and clot prevention are tailored to the person. Gloucestershire Hospitals describes a typical stay of five to ten days, but complications, foot care needs and home support can change the stay. Ask what must happen before discharge and what the operation actually involved.

The goal may be to improve walking, relieve pain at rest, help a wound heal or reduce the risk of limb loss. Benefit depends on the reason for surgery, condition of the foot, artery anatomy and other health problems. Even with improved blood flow, wound care or further procedures may be needed, and pain or limited mobility can have other causes. Ask how the team will judge whether the operation met your goal.

A graft can block early or narrow or block later. This can reduce blood flow again and may require urgent treatment, a further procedure or, in some circumstances, amputation. Wound or graft infection, bleeding requiring transfusion, nerve injury or altered skin sensation and leg swelling can occur. Major surgery can also involve heart attack, stroke, kidney problems, chest infection, blood clots or death. Risk varies with the operation, urgency and your health.

A clot in a deep vein and a blocked arterial graft are different problems, although both need prompt attention. Teams assess clot-prevention measures individually. Do not start compression stockings on your own: they may be unsuitable in arterial disease. Ask the vascular team which measures are safe for your legs and how long they are needed.

Recovery can take months, and tiredness may last weeks or longer. Plan a mixture of rest and gradual activity rather than expecting to feel back to normal immediately. Cambridge University Hospitals suggests a short walk at least daily and gentle activity around the house. Follow your own team’s instructions, especially if you have a foot wound, restricted weight bearing or other mobility needs. Tell the team if pain stops you moving or progress is not going as expected.

Incisions may be closed with dissolvable stitches, stitches needing removal or clips. Before discharge, ask how and when the dressings should be changed, when you can wash and who will remove any clips or stitches. A little wound oozing can occur; arrangements for nursing care should be made if needed. Increasing redness, heat, pain, discharge or fever requires urgent advice, particularly because an infection can affect a graft.

Swelling in the operated leg and patches of numbness or tingling around a wound can occur and may take months to settle. Gloucestershire Hospitals suggests raising the leg when resting and avoiding long periods with it down to help swelling; ask your own team if this is appropriate for you. A suddenly painful, cold, pale, numb or weak foot needs emergency assessment. New painful swelling or possible infection needs urgent advice, not just routine monitoring.

Ask for a plan for pain relief, including how to reduce stronger medicines and what to do about constipation or nausea. Return to work depends on your recovery and the demands of the job. Cambridge advises avoiding strenuous activity for about four to six weeks and suggests sex can resume after about six weeks or when comfortable. Your own plan may differ; ask about lifting, caring responsibilities, stairs and any help needed at home.

Cambridge University Hospitals advises avoiding driving for about four to six weeks after a leg bypass and being able to perform an emergency stop safely before returning. This is patient guidance, not a fixed clearance for everyone. Discuss your recovery, pain, movement and any medicines that could impair driving with your team, and check your insurance before driving again.

For Great Britain, GOV.UK says car and motorcycle drivers do not need to tell DVLA about peripheral arterial disease itself, while bus, coach and lorry drivers must tell DVLA. GOV.UK also says you must tell DVLA if you have had an operation and are still unable to drive three months later. Other conditions may have their own reporting requirements. Northern Ireland uses the DVA; check the applicable medical reporting rules with DVA and your clinical team.

The bypass needs follow-up even when symptoms improve. Gloucestershire Hospitals describes an outpatient appointment around four to six weeks after discharge. For a vein graft it arranges regular ultrasound scans during the first year; the surgeon may also request scans for a synthetic graft. Cambridge describes a different local schedule for vein grafts, often every three months in the first year. Your surgeon will explain your own schedule and how you will receive results.

Duplex ultrasound looks at blood flow in the graft and may identify a narrowing. If a problem is found, the team may recommend further imaging, observation or a procedure. Ask whether you should check a pulse and ask a clinician to show you how if they recommend it. Do not let a home pulse check delay emergency help for a sudden change in the leg or foot.

If you have a foot ulcer or infection, wound care and follow-up may continue after blood flow is restored. People with diabetes may need coordinated assessment by a specialist foot service. Check your feet, protect them from injury and report new wounds or colour changes promptly; reduced sensation can make injuries less noticeable. Suspected gangrene needs emergency assessment.

A bypass creates a route around one blockage; it does not cure atherosclerosis. Your discharge medicines may include an antiplatelet such as aspirin or clopidogrel and a statin to reduce cardiovascular risk. The exact regimen depends on the graft, other conditions and bleeding risk. Check what has changed from your previous medicines, how long to take each one and who will review it. Do not stop or substitute prescribed medicines without discussing it with your clinician.

For some adults with symptomatic PAD at high risk of ischaemic events, NICE recommends low-dose rivaroxaban plus aspirin as an option within its marketing authorisation. This combination can reduce some cardiovascular events but increases bleeding risk. A clinician should assess bleeding risk and discuss benefits and harms before starting it and review treatment regularly. It is not a routine instruction for everyone after bypass and may be unsuitable alongside other blood-thinning medicines or with certain health conditions.

Smoking cessation support, activity appropriate to your recovery, and management of cholesterol, blood pressure and diabetes remain important. Ask your GP and vascular team about local support and an activity plan. Seek help with side effects or the cost or practicalities of taking medicines so the plan can be reviewed rather than abandoned. Attend follow-up even if walking or wound healing has improved.