Association Between Preoperative Blood Transfusion and Postoperative Venous Thromboembolism: Review Meta-Analysis

doi:10.1016/j.avsg.2020.11.033

Annals of Vascular Surgery

Volume 73, May 2021, Pages 463-472

https://doi.org/10.1016/j.avsg.2020.11.033 Get rights and content

Background

Several studies have shown that preoperative blood transfusion is associated with postoperative venous thromboembolism (VTE). In this study, a meta-analysis was performed to explore the relationship between preoperative blood transfusion and postoperative VTE.

Methods

Published articles were identified through a comprehensive review of PubMed and EMBASE. Data from studies reporting relative risks, odds ratios, or hazard ratios comparing the risk of postoperative VTE among participants who had preoperative blood transfusion versus those without preoperative blood transfusion were analyzed. A random-effect model was used to calculate pooled odds ratios and 95% confident intervals (CIs).

Results

Eight studies, which included 3,504,778 participants, aligned with our inclusion criteria and were included in the meta-analysis. Pooled analysis showed an association between preoperative blood transfusion and postoperative VTE, with an odds ratio of 2.95 (95% CI: 1.65–5.30; I² = 89.1%). In subgroup analyses, the positive association between preoperative blood transfusion and postoperative VTE was still exist in studies with confounders adjustment. Sensitivity analysis by one-study-removed analysis confirmed the robustness of our results.

Conclusions

Our study indicated that preoperative blood transfusion was associated with higher odds of postoperative VTE. Further large-scale prospective cohort studies are needed to investigate the causality between preoperative blood transfusion and postoperative VTE.

Introduction

Venous thromboembolism (VTE) is a major postsurgical complication, which is associated with disastrous impacts on surgical outcomes and substantial health care costs.¹ VTE includes deep vein thrombosis (DVT) and pulmonary embolism (PE).² In a UK population–based cohort study, the estimated overall VTE rate within 90 days of general surgery is 23.7 per 1,000 patient-years, and VTE accounts for 37.5% of 90-day deaths.³

Several VTE preventative guidelines and recommendations have been issued from different surgical societies, including intraoperative leg elevation, intermittent pneumatic compression, and low-molecular-weight heparin.⁴^,⁵ In addition to surgery, multiple independent risk factors for VTE have been reported, including increasing patient age, body mass index, trauma/fracture, active cancer, and neurologic disease with leg paresis.⁶ Although independent VTE risk factors and effective prophylaxis is available, the occurrence of VTE seems to be relatively constant or even increasing.⁷ Thus, it is important to identify more potential risk factors associated with postoperative VTE.

Recently, increasing evidence supports the potential association between blood transfusion and thrombosis.⁸^,⁹ Transfused blood has been proposed to modulate the inflammatory cascade and contribute to hypercoagulation.¹⁰ The previous study has shown that perioperative blood transfusions may increase the risk of infection, cardiovascular diseases, renal failure, malignancy, hemolytic reactions, volume overload, and death.¹¹ Preoperative blood transfusion is common in patients undergoing surgery, especially in patients with preoperative anemia.⁸^,⁹ However, there are limited studies that have explored the effect of preoperative blood transfusions on postoperative outcomes, especially postoperative VTE. In this study, to investigate this possible association, we conducted a systematic review and meta-analysis of observational studies to evaluate the relationship between preoperative blood transfusion and postoperative VTE.

Section snippets

Methods

This review meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement.¹²

Literature Search and Characteristics of Included Studies

Database searches retrieved 13,328 articles from two electronic databases (PubMed and EMBASE). A total of eight articles met the inclusion criteria.⁸^,⁹^,15, 16, 17, 18, 19, 20 The selection process is presented as a flow diagram, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (Fig. 1).

Table I shows a summary of the studies that have been included. Of the eight studies included in our analysis, with one prospective cohort and seven cross-sectional studies.

Discussion

A great deal of epidemiologic studies has shown a possible link between preoperative blood transfusion and postoperative VTE; however, there are no comprehensive analyses of these inconsistent studies. Thus, we perform a meta-analysis on the association between preoperative blood transfusion and postoperative VTE. In summary, our results indicated that there is a positive relationship between preoperative blood transfusion and postoperative VTE (OR = 2.95, 95% CI: 1.65–5.30, I² = 89.1%).

Conclusion

In summary, our meta-analysis demonstrated a significant positive association between preoperative blood transfusion and postoperative VTE. However, related studies are still deficient. To exclude the contingency of this study, further large-scale prospective cohort studies are required to confirm the relationship between preoperative blood transfusion and postoperative VTE.

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Cited by (4)

Is perioperative blood transfusion associated with postoperative thromboembolism or infection after metastatic spinal tumor surgery?
2023, Clinical Neurology and Neurosurgery
Retrospective cohort.
Patients with metastatic spine disease who undergo surgical intervention have a high risk of requiring red blood cell (RBC) transfusion. Perioperative transfusion has been independently associated with increased risk of venous thromboembolic (VTE) and infectious complications following orthopedic procedures and degenerative spinal intervention; however, literature within spine oncology is limited.
To determine the association between perioperative RBC transfusion and postoperative VTE or infection following spinal tumor surgery.
A total of 153 patients who underwent surgery for spinal metastases between April 2012 and April 2022 were included. Medical records were reviewed to identify RBC transfusion administered either intraoperatively or within 96 h following surgery. The primary endpoints were: 1) development of any VTE or 2) development of any infection within 30 days following surgery. Any VTE was defined as deep vein thrombosis or pulmonary embolism, and any infection was defined as pneumonia, meningitis, Clostridium difficile infection, urinary tract infection, surgical site infection, or sepsis. Logistic regression analyses were performed.
Of the 153 patients included in the study, 43 % received a perioperative RBC transfusion. The overall incidence of postoperative VTE and infection was 15 % and 22 %, respectively. In univariate analysis, perioperative transfusion was not associated with postoperative VTE (odds ratio [OR] 2.41; 95 % confidence interval [CI] 0.97–6.00; p = 0.058) but was associated with infection (OR 3.02; 95 % CI 1.36–6.73; p = 0.007). After adjusting for confounders such as performance status, operative time, and surgical extent, transfusion was not associated with both VTE (OR 1.25; 95 % CI 0.36–4.32; p = 0.727) or infection (OR 1.86; 95 % CI 0.70–4.92; p = 0.210). While not statistically significant, sub-analyses demonstrated a trend towards increased VTE incidence in patients requiring transfusion earlier (within 24 h) as opposed to later postoperatively.
We found that perioperative transfusion was not an independent predictor of 30-day postoperative VTE or infection in patients undergoing metastatic spinal surgery. Further exploration of time-dependent transfusion outcomes is warranted.
Tissue plasminogen activator resistance is an early predictor of posttraumatic venous thromboembolism: A prospective study from the CLOTT research group
2022, Journal of Trauma and Acute Care Surgery
Analysis of influencing factors for postoperative deep vein thrombosis in elderly patients with inguinal hernia
2022, Chinese Journal of Digestive Surgery
Transfusion timing relative to surgery does not impact outcomes in hip fracture patients
2022, European Journal of Orthopaedic Surgery and Traumatology

: Funding: None.

: Availability of data and material: Not applicable.

: Consent for publication: Not applicable.

: Ethics approval and consent to participate: not applicable.

: Authors’ contributions: All authors provided contributions to con-design of this research and approve this version of article to be published. W.C.C., K.H.Y., and L.J.F. determined the search strategy. W.C.C. and K.H.Y. conducted the selection of relevant studies and data extraction separately. W.C.C. and L.X.L. evaluated the quality of each study independently. W.C.C. L.X.L. and L.J.F did the analyses and outcomes. W.C.C. and L.J.F. drafted the article. All authors have read and approved the final article.

: Conflicts of interest: The authors declare that they have no conflicts of interest relevant to the content of this article.

View full text

General ReviewAssociation Between Preoperative Blood Transfusion and Postoperative Venous Thromboembolism: Review Meta-Analysis

Background

Methods

Results

Conclusions

Introduction

Section snippets

Methods

Literature Search and Characteristics of Included Studies

Discussion

Conclusion

Clin Neurol Neurosurg

J Orthop

J Orthop

Am J Surg

J Vasc Surg

World Neurosurg

Thromb Res

Am J Cardiol

Redox Biol

J Proteomics

Risk factors for deep vein thrombosis and pulmonary embolism: a population-based case-control study

Arch Intern Med

Current concepts in deep vein thrombosis and pulmonary embolism after trauma

Curr Orthop Pract

Risk of post-discharge venous thromboembolism and associated mortality in general surgery: a population-based cohort study using linked hospital and primary care data in England

PLoS One

Efficacy of intermittent pneumatic compression for venous thromboembolism prophylaxis in patients undergoing gynecologic surgery: a systematic review and meta-analysis

Oncotarget

Preventing deep vein thrombosis after stroke: strategies and recommendations

Curr Treat Options Neurol

The epidemiology of venous thromboembolism

J Thromb Thrombolysis

General Review
Association Between Preoperative Blood Transfusion and Postoperative Venous Thromboembolism: Review Meta-Analysis