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OBJECTIVE:
Increased transfusion requirements have been identified as a risk factor for multiple adverse outcomes in patients undergoing lower extremity revascularization. However, previous studies have not identified clear predictors for bleeding in this patient population. In this study we aim to identify the predictors for bleeding in patients with critical limb ischemia (CLI) and claudication.
METHODS:
All patients undergoing intervention for CLI or claudication between 2011 and 2012 in the Vascular Targeted NSQIP database were identified and analyzed separately. Bleeding was defined as transfusion or return to the operating room for bleeding. Patients undergoing emergent intervention were excluded. Patient demographics and perioperative risk factors including pre-operative anticoagulation, hematocrit, and preoperative transfusion requirements were identified. Univariate analysis was completed using Chi-Square, Fisher Exact, and T-test. A stepwise multivariate logistic regression was utilized to compare independent predictors.
RESULTS:
5163 patients undergoing revascularization were identified including 3067 patients undergoing intervention for CLI and 2096 undergoing intervention for claudication. A hematocrit less than 35 was an independent risk factor for bleeding regardless of operative indication (OR 3.0, 95% CI 2.5-3.5). A dependent functional status was an independent predictor of bleeding in patients undergoing open procedures for critical limb ischemia (OR 1.7, 95% 1.3-2.2). Uncorrected anticoagulation or a bleeding disorder was an independent predictor for bleeding in claudicants undergoing open procedures (OR 2.1, 95% CI 1.44-2.97). There are no clear predictors of bleeding for claudicants undergoing endovascular intervention, likely due to very low rates of bleeding.
CONCLUSION:
A preoperative hematocrit less than 35 is an independent predictor of bleeding in patients undergoing intervention for both critical limb ischemia and claudication. Functional status is predictive of bleeding in critical limb ischemia and uncorrected anticoagulation or bleeding disorders are predictive in patients with claudication. These factors should be accounted for in preoperative planning to identify patients requiring transfusion in the perioperative period.

Predictors of bleeding by operative intervention

	Claudication and Critical Limb Ischemia	Claudication				Critical Limb Ischemia
	All Cases	Suprainguinal Endovascular	Supringuinal Open	Infrainguinal Endovascular	Infrainguinal Open	Suprainguinal Endovascular	Suprainguinal Open	Infrainguinal Endovascular	Infrainguinal Open
Hematocrit <35	3.0 (2.2-4.7)	Nonsignificant	4.1(1.8-9.2)	Nonsignificant	3.2 (1.9-5.2)	4.8 (1.9-12.2)	3.2(1.5-6.8)	3.5 (2.1-5.7)	2.2 (1.7-3.9)
Dependent Functional Status	1.8 (1.4-2.7)	Nonsignificant	Nonsignificant	Nonsignificant	Nonsignificant	Nonsignificant	4.8(1.6-14.3)	Nonsignificant	1.8 (1.3-2.6)
Uncorrected Anticoagulation or Bleeding Disorder	1.6 (1.3-1.9)	Nonsignificant	4.1(1.8-9.3)	Nonsignificant	2.5 (1.5-4.1)	Nonsignificant	Nonsignificant	Nonsignificant	Nonsignificant
Preoperative Sepsis	2.9 (1.7-5.2)	Nonsignificant	Nonsignificant	Nonsignificant	Nonsignificant	Nonsignificant	Nonsignificant	Nonsignificant	Nonsignificant
Steroid Use	Nonsignificant	Nonsignificant	Nonsignificant	Nonsignificant	Nonsignificant	Nonsignificant	Nonsignificant	Nonsignificant	2.2 (1.4-3.5)
Smoking	Nonsignificant	Nonsignificant	Nonsignificant	Nonsignificant	Nonsignificant	Nonsignificant	Nonsignificant	2.2(1.3-3.5)	Nonsignificant
Dialysis	Nonsignificant	Nonsignificant	Nonsignificant	Nonsignificant	Nonsignificant	Nonsignificant	Nonsignificant	Nonsignificant	1.8 (1.2-2.6)