Daniel G. Clair, MD
VASCULAR DISEASE MANAGEMENT 2010;7:E158
The article by Xenos et al reinforces findings from a number of previous studies which have assessed the perioperative and postoperative outcomes in patients who have undergone transfusions following varied surgical procedures. In this article, the authors have clarified the situation in patients undergoing surgical revascularization for lower-extremity ischemia. This is a population with significant underlying cardiovascular disease and in particular, significant risk related to perioperative myocardial ischemic episodes as well as arrhythmias and because of the advanced age, mortality. Clearly, the data show the transfusions increase the risk of nearly every perioperative complication and the more significant the transfusion, the more dramatic the effects. Blood products, like any other physician-initiated intervention, have both positive and negative effects. Surgeons in particular have over time become liberal in the use of blood products and, in particular, red blood cells, to deal with perioperative anemia. It is clear from this study that the liberal approach to blood transfusion should be reassessed. While it is imperative to maintain adequate hemoglobin levels, the exact value necessary in order to lower the risk of perioperative myocardial ischemic events while minimizing the use of transfusions has not been identified. As the authors point out, it would be helpful to have a larger study to assess the point at which the benefits of transfusion outweigh the risks. For the time being, it seems clear that the clinician can probably maintain a hemoglobin level lower than initially thought necessary and likely reduce the risk for those individuals undergoing this operative procedure. In time, and with continued study, we can hopefully come to a better understanding of how to manage perioperative blood products to reduce the risk to the patient from the blood products as well as from their underlying cardiovascular disease. This study likely also gives impetus to further investigation into alternative products for maintenance of blood oxygen-carrying capacity. One would hope that we would be able to pursue or identify an oxygen-carrying compound, which may be utilized as an alternative to red blood cell transfusions. Hopefully, the use of this product might alleviate a number of the issues related especially to the immunocompromise suffered by patients undergoing blood transfusions. This is an important improvement in the understanding of the risks of blood transfusion, and the authors should be congratulated on reinforcing, particularly related to this patient population, the specific risks related to red blood cell transfusion.
From the Department of Vascular Surgery, Cleveland Clinic, Cleveland, Ohio. The author reports no conflicts of interest regarding the content herein. Address for correspondence: Daniel G. Clair, MD, Vascular Surgery, The Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195.