Perioperative Blood Transfusions Are Associated with a Higher Incidence of Thromboembolic Events After TKA: An Analysis of 333,463 TKAs

Abstract

Background Given the morbidity, mortality, and financial burden associated with venous thromboembolism (VTE) after TKA, orthopaedic providers continually seek to identify risk factors associated with this devastating complication. The association between perioperative transfusion status and VTE risk has not been thoroughly explored, with previous studies evaluating this relationship being limited in both generalizability and power. Questions/purposes Therefore, we sought to determine whether perioperative transfusions were associated with an increased risk of (1) pulmonary embolism (PE) or (2) deep vein thrombosis (DVT) after primary TKA in a large, multi-institutional sample. Methods The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was implemented for our analysis. The definitions of complications, such as DVT and PE, and risk adjustment validation is monitored by the central ACS NSQIP office to ensure participating hospitals are adhering to the same guidelines to log patients. Additionally, both preoperative and intraoperative/72 hour postoperative transfusion status is included for all patients. Therefore, ACS NSQIP was determined to be the most appropriate database for our analysis. All patients who underwent primary TKA between 2011 and 2018 were identified using Current Procedural Terminology code 27447. Primary TKAs designated as “non-elective” were excluded, thereby providing a cohort composed solely of patients undergoing unilateral primary elective TKA for further analysis. The final analysis included 333,463 patients undergoing TKA (mean age 67 ± 9 years, 62% female). Preoperative transfusions were received by < 0.01% (48 of 333,463) of the patients, while 4% (14,590 of 333,463) received a transfusion within the interim between the start of surgery up to 72 hours postoperatively. All missing values were imputed through multiple imputation by chained equation to avoid variable availability-based selection and the subsequent listwise deletion-associated bias in the estimate of parameters. A multivariable logistic regression analysis was conducted using variables identified in a univariate model to calculate adjusted odds ratios and 95% confidence intervals for risk factors associated with symptomatic DVT and/or PE. For variables that maintained significance in the multivariable model, an additional model without confounders was used to generate fully adjusted ORs and 95% CIs. A propensity score matched comparison between recipients versus nonrecipients (1:1) of transfusion (preoperative and intraoperative/72 hours postoperative) was then conducted to evaluate the independent association between DVT/PE development and patients’ transfusion status. Significance was determined at a p value < 0.05. Results Adjusted multivariable regression analysis accounting for patient age, sex, race, BMI, American Society of Anesthesiologists (ASA) class and baseline comorbidities demonstrated the absence of an association between preoperative (OR 1.75 [95% CI 0.24 to 12.7]; p = 0.58) or intraoperative/72 hours postoperative (OR 1.12 [95% CI 0.93 to 1.35]; p = 0.23) transfusions and higher odds of developing PE. Similar findings were demonstrated after propensity score matching. Although multivariable regression demonstrated the absence of an association between preoperative transfusion and the odds of developing DVT within the 30-day postoperative period (OR 1.85 [95% CI 0.43 to 8.05]; p = 0.41), intraoperative/postoperative transfusion was associated with higher odds of DVT development (OR 3.68 [95% CI 1.14 to 1.53]; p < 0.001) relative to transfusion naïve patients. However, this significance was lost after propensity score matching. Conclusion After controlling for various potential confounding variables such as ASA Class, age, anesthesia type, and BMI, the receipt of an intra- or postoperative transfusion was found to be associated with an increased risk of DVT. Our findings should encourage orthopaedic providers to strictly adhere to blood management protocols, further tighten transfusion eligibility, and adjust surgical approach and implant type to reduce the incidence of transfusion among patients with other DVT risk factors. Additionally, our findings should encourage a multidisciplinary approach to VTE prophylaxis and prevention, as well as to blood transfusion guideline adherence, among all providers of the care team. Level of Evidence Level III, therapeutic study.

Blood transfusions increase the risk for venous thromboembolism events following total joint arthroplasty

“…The results of their subgroup analysis showed an adjusted OR of 1.7 (95% CI 1.5–2.0) for developing VTE following blood transfusion. Consistent with these findings, Acuña et al utilized the same database and timeframe to examine the association in 333,463 patients undergoing TKA 5 . While they found an initial association between perioperative blood transfusions and DVT (adjusted OR 1.32, 95% CI 1.14–1.53), their propensity score model failed to confirm this association.…”

“…Recently published registry data, all from the NSQIP database, have suggested an association between blood transfusions and VTE following orthopedic procedures 4 , 5 . Goel et al analyzed 750,937 patients from this database, of which 153,320 underwent orthopedic surgery.…”

“…A review of the current literature shows that registry data has consistently demonstrated an association between blood transfusions and VTE. However, all published studies to date have utilized the same National Surgical Quality Improvement Program (NSQIP) database 4 , 5 , rendering them susceptible to inherent limitations associated with registry data 17 , 18 . By contrast, several institutional studies, including one published from our institution, have failed to demonstrate a clear independent association 6 , 19 .…”

Perioperative red blood cell infusion and deep vein thrombosis in patients with femoral and pelvic fractures: a propensity score matching

“…In this study, PSM was used to control confounders related to DVT, and the formation or progression of DVT after RBC infusion was taken as the end point to further analyze the possible causal relationship between RBC infusion and DVT during the perioperative period. Studies on RBC infusion and DVT in patients with current bone trauma also mostly focus on surgical types such as total joint replacement patients [ 17 , 18 ]. In this study, patients with femoral and pelvic fractures were included, and more attention was paid to the correlation between RBC infusion and DVT in different bone trauma types.…”

Perioperative red blood cell infusion and deep vein thrombosis in patients with femoral and pelvic fractures: A propensity score matching

“…In this study, PSM was used to control confounders related to DVT, and the formation or progression of DVT after RBC infusion was taken as the end point to further analyze the possible causal relationship between RBC infusion and DVT during the perioperative period. Studies on blood transfusion and DVT in patients with current bone trauma also mostly focus on surgical types such as total joint replacement patients [9,10] . In this study, patients with femoral and pelvic fractures were included in the study, and more attention was paid to the correlation between transfusion and DVT in different bone trauma types.…”