A preoperative risk score for transfusion in infrarenal endovascular aneurysm repair to avoid type and cross

• Published in: Journal of vascular surgery Vol. 67; no. 2; pp. 442 - 448
• Main Authors: O'Donnell, Thomas F.X., Shean, Katie E., Deery, Sarah E., Bodewes, Thomas C.F., Wyers, Mark C., O'Brien, Kerry L., Matyal, Robina, Schermerhorn, Marc L.
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.02.2018
• Subjects: Aged; Aged, 80 and over; Aortic Aneurysm, Abdominal - blood; Aortic Aneurysm, Abdominal - diagnostic imaging; Aortic Aneurysm, Abdominal - economics; Aortic Aneurysm, Abdominal - surgery; Blood Grouping and Crossmatching - economics; Blood Loss, Surgical - prevention & control; Blood Transfusion - economics; Blood Vessel Prosthesis Implantation - adverse effects; Blood Vessel Prosthesis Implantation - economics; Clinical Decision-Making; Cost Savings; Cost-Benefit Analysis; Decision Support Techniques; Endovascular Procedures - adverse effects; Endovascular Procedures - economics; Female; Health Care Costs; Hematocrit; Humans; Logistic Models; Male; Odds Ratio; Predictive Value of Tests; Preoperative Care; Registries; Reproducibility of Results; Retrospective Studies; Risk Assessment; Risk Factors; United States; Unnecessary Procedures - economics; United States
• ISSN: 0741-5214; 1097-6809
• DOI: 10.1016/j.jvs.2017.05.108

Preoperative type and cross are often routinely ordered before elective endovascular aneurysm repair (EVAR), but the cost of this practice is high, and transfusion is rare. We therefore aimed to stratify patients by their risk of transfusion to identify a cohort in whom a type and screen would be sufficient. We queried the targeted vascular module of the National Surgical Quality Improvement Program (NSQIP) for all elective EVARs from 2011 to 2015. We included only infrarenal aneurysms and excluded ruptured aneurysms and patients transfused within 72 hours preoperatively. Two-thirds of the cases were randomly assigned to a model derivation cohort and one third to a validation cohort. We created and subsequently validated a risk model for transfusion within the first 24 hours of surgery (including intraoperatively), using logistic regression. Between 2011 and 2015, there were 4875 patients who underwent elective infrarenal EVAR, only 221 (4.5%) of whom received a transfusion within 24 hours of surgery. The frequency of transfusion during the study period declined monotonously from 6.5% in 2011 to 3.2% in 2015. The factors independently associated with transfusion were preoperative hematocrit <36% (odds ratio [OR], 3.4 [95% confidence interval, 2.1-5.4]; P < .001), aortic diameter (per centimeter increase: OR, 1.2 [1.03-1.4]; P = .02), preoperative dependent functional status (OR, 2.5 [1.1-5.5]; P = .03), and chronic obstructive pulmonary disease (OR, 1.7 [1.04-2.9]; P = .04). A risk prediction model based on these criteria produced a C statistic of 0.69 in the prediction cohort and 0.76 in the validation cohort and a Hosmer-Lemeshow goodness of fit of 0.62 and 0.14, respectively. A score of <3 of 9, corresponding to a <5% probability of transfusion, would avoid preoperative type and cross in 86% of patients. Of the 4203 patients (86%) with a hematocrit >36%, only 6 (0.1%) had a risk score of >3. Perioperative transfusion for EVAR is becoming increasingly uncommon and is predicted well by a transfusion risk score or simply a hematocrit of <36%. Application of this risk score would avoid unnecessary type and cross in the majority of patients, leading to significant savings in both time and cost.