You've heard of a heart bypass, but what about an arm bypass?
We've all heard of the term “bypass surgery” and often assume it’s associated with the heart.

Most of the time it is, and the doctor who carries out a coronary artery bypass surgery is the cardiothoracic surgeon.

A vascular surgeon can also perform bypass surgeries, but on arteries outside the heart.

The operation is done to treat a narrowed or blocked artery by creating a detour, i.e. bypass, around a section of the affected artery.

Last year (2023), a local vascular surgeon from a private hospital carried out a challenging arm bypass surgery on a foreign patient, possibly the first of its kind in the country.

The story begins like this.

Sudden weakness

It was just another ordinary day in the life of Indonesian civil servant Rayadi Saputra. Dr Yow checks the blood flow through Rayadi’s graft using a Doppler ultrasound machine. — MUHAMAD SHAHRIL ROSLI/The Star

Most evenings, the 55-year-old would partake in some kind of physical activity after work.

Last September (2023), he was playing badminton when he started experiencing prickling pins-and-needles sensations along his left arm.

It became progressively more numb and weak, until eventually, he couldn’t lift his arm up.

“I was unsure what was happening because there was no pain.

“I stopped playing and went to the hospital.

“The doctor did a CT (computed tomography) scan, which revealed a blocked artery in the arm.

“He said I had to undergo an operation, but I didn’t want to at that time because I didn’t think it was serious,” shares Rayadi, who is from Pekan Baru, a city in the province of Riau in Sumatra.

Instead, he opted for alternative treatment, which included seeing a sinseh, drinking herbal concoctions and going for nerve massages.

A month passed, and as he didn’t see any improvement, he decided to go ahead with the suggested surgery last October (2023).

He says: “Two weeks post-operation, my arm was still numb, cold and weak, plus my middle finger had started to blacken.

“Since I was doing my yearly health check-ups at a private hospital in Malaysia, I thought about consulting the doctors there, but alas, they didn’t have a vascular surgeon.

“So I sourced the Internet and found one in Kuala Lumpur.”

That was how Rayadi landed in Dr Yow Kuan Heng’s clinic.

The consultant vascular and endovascular surgeon notes: “He had a failed removal of clot (embolectomy) from his brachial artery in Indonesia.

“Unfortunately, the operation resulted in his entire major arm artery being blocked, and he came to me with a cold, numb hand and digital gangrene.

“We repeated his CT angiogram, and yes, the clots were still there, so I suggested surgery.

“He also had a complete left carotid artery blockage, which made me suspect an inherited clotting disorder.”

The relevant blood tests were carried out, along with an echocardiogram and Holter monitor test to rule out a cardiac (heart) source for his clotting problem.

Except for smoking and having mild cholesterol, Rayadi was otherwise trim and healthy.

He agreed to the second operation.

Bypassing the ‘jam’

At the operating theatre, Dr Yow used endovascular techniques such as on-table angiography to get an accurate road map of where blockages are and what needs to be done to bypass them or remove the clot.

Generally, arm bypass surgeries are rare because the arm has plenty of collateral circulation (i.e. alternate or back-up blood vessels) that takes over when one artery becomes blocked or damaged.

Dr Yow gives this analogy: “If there is a traffic jam along the Federal Highway, there are plenty of other routes one can take.

“Similarly, the arm has a lot of collaterals around the shoulder and elbow joints, so sometimes, you can get by without intervening if there is a ‘jam’.

“[This is] compared to the leg, which has fewer collaterals – a block will cause the leg to turn blue, get numb or cause gangrene quicker.”

During the operation, Dr Yow removed clots from Rayadi’s subclavian, axillary and brachial arteries before performing a bypass graft using a vein from the same arm (see illustration).

In peripheral arterial surgery, there is an option to use a synthetic graft, but the patient’s own vein, which is more compliant and resistant to infection, works best for smaller vessel bypasses, although it takes much more work to harvest it.

The graft was tunnelled underneath the pectoralis major muscle, running down the arm to the elbow.

It was then sutured to Rayadi’s axillary artery beneath his collarbone (clavicle) and onto his ulnar artery below the elbow to avoid the scarred and blocked brachial artery.

Drenched in sweat, Dr Yow and his team left the operation theatre 10 hours later, happy with their work.

The first 24 hours in intensive care is crucial and the surgeon constantly assessed Rayadi’s pulses and used the non-invasive Doppler ultrasound machine to measure blood flow through the graft.

“If the blood is flowing well, we should get a nice signal – a biphasic, whooshing sound.

“If the blood is not flowing, there will be no sound,” explains Dr Yow, who spent more than two decades working in the United Kingdom before returning to Malaysia last year (2023).

Everything seemed to be going well, but 48 hours later, the graft blocked again.

From being warm and pink, Rayadi’s arm was now cold and pale.

Dr Yow was heartbroken.

Second surgery

So, the team wheeled Rayadi back to the operation theatre to do a revision surgery. Using ultrasound, Dr Yow marked the arm vein to harvest for the first bypass surgery.

Further exploration and imaging tests showed he had an injury to his radial artery – likely from his surgery back home – and clots in the ulnar artery, leading to a restricted outflow of blood.

Dr Yow recalls: “The nature of vascular surgeries is that things may not always work out the first time.

“I asked myself, what can I do different?

“We were heading into uncharted territory because he already had a lot of scar tissues from the previous two surgeries.

“It’s not a good idea to use the same vein again because it’s full of clots, so I had to redo the bypass by taking another vein from the leg for the graft.”

To improve outflow, Dr Yow infused a clot-busting medication called alteplase into the downstream forearm arteries to open them up further.

To further improve outflow and reduce resistance to the new graft, he reconstructed the brachial artery using a combination of Rayadi’s own vein and tissue-engineered bovine pericardium up to the first elbow collaterals.

This time, the surgery took eight hours.

A day, two, three, then almost three weeks passed – the graft appeared to be functioning well.

There were cheers and tears all around when the patient was discharged.

Rayadi broke down and cried for 10 minutes, while Dr Yow, blinking back tears, sat quietly and held his hands.

“Vascular surgery is either very satisfying or very unforgiving.

“If we didn’t operate, he would’ve lost functionality of his arm.

“I’m glad we got it right after two operations and I must credit the whole hospital team for making this possible.”

However, it wasn’t a happy ending just yet.

A setback

How the bypass was done. — Graphic by Dr YOW KUAN HENG; refined by StarGraphics

In March (2024), Rayadi returned for his follow-up appointment.

He was feeling better, part of the gangrene had dropped off and he had regained 70% functionality of his left arm.

Recovery was on track until the tests showed stenosis (narrowing) at the axillary artery.

The unexpected find shocked the doctor and saddened the patient.

The results of earlier blood tests showed Rayadi indeed had an underlying form of genetic thrombophilia called Protein C and Protein S deficiency.

In thrombophilia, the blood has an increased tendency to form clots.

He was immediately started on anticoagulants (blood thinners) as an addition to his existing aspirin.

Dr Yow says: “The signal on the Doppler ultrasound was slow – an indication that the graft was about to fail – so we did a CT scan and found the stenosis.

“In the early stages of stenosis, there are no symptoms; thankfully, we caught it early before the clot formed, and we did an angioplasty.”

During the latest procedure, Rayadi remained calm and surrendered to the Almighty.

“What else could I do?” he asks.

A week later, he boarded a flight home after being given the all-clear, accompanied by his missus.

Their three adult children hold the fort in Pekan Baru whenever their parents go on medical trips.

Rayadi has no medical insurance outside Indonesia, and has to bear all financial costs himself.

“Health is important, and although my duit habis (money is gone), I leave everything in the hands of the surgeon as he knows best.

“Many people ask me why I don’t seek treatment in Jakarta.

“I prefer to come to Malaysia as it takes only 45 minutes by flight as compared to the two hours to Jakarta.

“Besides, the Malaysian healthcare system is excellent and the specialists are knowledgeable, which makes me confident of the treatment,” he says.

These days, Rayadi has quit smoking, eats healthier and spends quality time with family.

“Dah takut! Empat kali cukup! (I’m scared, four times is enough!),” he chuckles.

Fingers crossed, all will be well during his follow-up check-up back in Malaysia in a fortnight (June 2024).
Wellness,Arm bypass surgery,vascular surgery,surgery,thrombophilia
A local vascular surgeon recently performed a rare arm bypass surgery – possibly the first in the country.