Chapter 14 Vascular 2026

Published: 28/04/2026

14.11 Patient Blood Management in Vascular Surgery

Dr Anita Sugavanam

Why do this Quality Improvement Project?

Vascular surgery is only second to cardiac surgery in the use of perioperative allogeneic blood components. This is in a climate of ever-present national blood shortage. Furthermore, preoperative anaemia and blood transfusion have been found to be independently associated with worse mortality, longer length of stay and major cardiovascular events in vascular surgical patients. The scale of the problem is large: In hospitalised patients aged 65 years and older, the prevalence of anaemia is estimated between 24 and 60% and 30-day mortality in these patients is at least two times higher. 

Background

The 3 pillars of patient blood management (PBM): optimising erythropoiesis, minimising blood loss and maximising anaemia tolerance (e.g. restrictive transfusion strategies, maintenance of normothermia, optimising oxygen delivery, minimising oxygen demand) need to be firmly embedded in vascular surgical units.  In addition, there are specific nuances for vascular surgical patients: they often have excessively inflamed and pro-thrombotic baseline coagulation; they suffer with co-morbidities that can predispose to anaemia; and are often prescribed anticoagulants and/or antiplatelet agents. Continuing or withholding these medications will affect choice of anaesthetic techniques in these complex patients. The risk of thrombosis and bleeding are both higher and need to be considered on a case-by-case basis. Vascular surgical procedures are associated with high risk of blood loss, yet patients require heparinisation peri-operatively for clamping/graft patency purposes. The post-operative pro-thrombotic period is also precarious for these patients and the success of their operations.  The Centre for Perioperative Care (CPOC) and Getting It Right First Time (GIRFT) recommend applying a PBM approach to achieving these goals:

Best Practice

Standard Suggested Measures
Optimising Erythropoesis

Pre-operative assessment and management of anaemia, including parenteral iron therapy, ideally 30 days before surgery (GPAS 2.4.7)

Special consideration to use of erythropoietin-stimulating agents (ESA), particularly in patients with renal impairment

 

 

 

 

 

 

 

 

 

% of anaesthetists familiar on a perioperative anaemia pathway

% elective vascular surgical patients who are anaemic (WHO definition Hb < 130g/dl)

% elective vascular surgical patients found to be anaemic at pre-op assessment who have a post treatment haemoglobin measured before surgery

% of anaemic vascular surgical patients with renal impairment who are taking an erythrocyte stimulating agent (unless contradicted)

 

 

 

 

 

 
Minimising Blood Loss

Patient-tailored continuation or cessation of antiplatelet and anticoagulant medications

 

 

 

% anaesthetists familiar/able to access bridging guidelines 

Proportion of cases where guidance has/has not been followed, % of surgical procedures delayed due to inappropriate continuation of anti-coagulant or anti-platelet medication

 

Departments should have:

Guidelines to direct reversal of anticoagulants and antiplatelet medications for emergency vascular surgical patients

 

A nominated haematologist for perioperative guidance

% anaesthetists familiar with use of anti Xa levels, idarucizumab, Andexanet alfa, 4-factor prothrombin concentrate

Audit of use of reversal agents and blood product transfusion needs in vascular surgical patients

 

Use of minimally invasive techniques where anatomically suitable (TEVAR and EVAR): 

Shared patient decision making as part of a multidisciplinary team involving surgeons, anaesthetists, haematologists, cardiologists where appropriate (GPAS 15.5.5)

 

 

% patients discussed at MDT: Harm from major blood loss and physiological insult > concerns for long term survival, post-operative ischaemia and risk of reintervention.

% of MDT meetings where an anaesthetist is present

 

 

 

Equipment and facilities, including cell salvage, should be available to manage major blood loss (GPAS 15.2.3)

 

 

 

 

 

 

 

 

 

 

% of anaesthetists familiar with local major haemorrhage protocol

% of cases where availability of blood and/or blood products is delayed

Participation in NHSBT national major haemorrhage audit 2025

% of cases where intra-operative cell salvage is employed.

% cases where allogeneic blood transfusion was avoided due to cell salvage

 

 

 

 

 

Use of Tranexamic Acid (TXA)

(NICE QS138)

 

% of patients with EBL > 500mls where TXA was considered (and/or given)

 

Use of Point of Care (POC) testing as part of major haemorrhage protocol (GPAS 3.3.13)

Use POC platelet-mapping

Use of Heparin POC test intra-operatively

 

 

 

 

 

 

% of cases of major haemorrhage where POC testing used

% of theatre staff familiar with running POC tests

% of anaesthetists able to interpret POC results

Number of cases where cancellation was avoided due to platelet mapping results

Audit use of POC ACT/heparinization tests in vascular surgery to guide heparin dosage

 

 

 

Equipment should be available to monitor and maintain normothermia (GPAS 15.2.7) 

 

 

 

% of cases where core temperature is measured (100%)

and active warming methods are used (100%)

% of cases where core temperature falls below 35oC 

 
Harness Physiological Reserve of Anaemia

Individualised Transfusion thresholds: Use of higher/liberal thresholds where risk of harm due to inadequate oxygen delivery considered high

 

 

 

% cases where transfusion threshold and reasoning documented in notes

Review incidence of anaemia and major cardiovascular events in M&M meetings

 

 

Advanced cardiovascular monitoring equipment should be available, this may include monitoring of invasive pressures, cardiac ischaemia and cardiac output.  (GPAS 15.2.*)

 

% of cases where any appropriate monitoring is not available (should be zero).

 

QI Methodology

  • An anaesthetist with PBM interest should be part of the Trust Transfusion Group
  • Participate in PQIP where data on preoperative anaemia, administration of TXA and relevant national QI projects are already structured.
  • Use of TXA and Cell Salvage to be added to WHO checklist
  • Participate in NHSBT Quality Insights Audit tool and National Comparative Audit of QS138: Recruit a transfusion practitioner to aid data collection. The audit tool focuses on iron supplementation and TXA administration, reassessment after blood transfusion and patient information.
  • An anaesthetist should regularly attend MDT meeting for complex cases where thrombotic and bleeding risks high
  • Business case for POC testing if not already in place as per national guidelines to aid major haemorrhage management
  • Business case for platelet mapping POC testing ability.

  • Local, regional or national database to collect platelet-mapping data on vascular surgical patients

     

References

  1. Fulvio Nisi, Luca Ratibondi, Mattia Hagger, Enrico Giustiniano, Federico Piccioni, Giovanni Badalamenti, et al
  2. Prognostic Impact of Anemia and Blood Transfusions on Cardiovascular Outcomes in Patients
  3. Undergoing Vascular Surgery: A Scoping Review,Journal of Cardiothoracic and Vascular Anesthesia,Volume 39, Issue 2,2025, Pages 511-525,
  4. Obi AT, Park YJ, Bove P, Cuff R, Kazmers A, Gurm HS, Grossman PM, Henke PK. The association of perioperative transfusion with 30-day morbidity and mortality in patients undergoing major vascular surgery. J Vasc Surg. 2015 Apr;61(4):1000-9.e1.
  5. Birmpili P, Cromwell DA, Li Q, Johal AS, Atkins E, Waton et al The Impact of Pre-Operative Anaemia on One Year Amputation Free Survival and Re-Admissions in Patients Undergoing
  6. Vascular Surgery for Peripheral Arterial Disease: a National Vascular Registry Study. Eur J Vasc Endovasc Surg. 2023 Aug;66(2):204-212.
  7. NHSBT Amber Alert https://nhsbtdbe.blob.core.windows.net/umbraco-assets-corp/36417/20250521-nhsbt-amber-alert-update-risk-of-red-alert.pdf
  8. Anaemia in the Perioperative Pathway – Centre for Perioperative Care
  9. https://cpoc.org.uk/guidelines-and-resources/guidelines/anaemia-perioperative-pathway
  10. Patient Blood Management. FSN 2025-05 https://hospital.blood.co.uk/patient-services/patient-blood-management/
  11. PQIP Report 2023-2024 https://pqip.org.uk/FilesUploaded/PQIP-Report2023-2024.pdf
  12. QS138 Quality Insights Audit Tool - Hospitals and Science – NHSBT https://hospital.blood.co.uk/audits/qs138-quality-insights-audit-tool/
  13. 2024 National Comparative Audit of NICE Quality Standard QS138 - Hospitals and Science – NHSBT https://hospital.blood.co.uk/audits/national-comparative-audit/reports-grouped-by-year/2024-national-comparative-audit-of-nice-quality-standard-qs138/
  14. NHSBT amber alert and use of tranexamic acid. Centre for Perioperative Care https://cpoc.org.uk/nhsbt-amber-alert-and-use-tranexamic-acid
  15. S Ofori, M Marcucci, J Harlock, D Conen, F K Borges, M Wang et al POISE-3 trial investigators, Effect of tranexamic acid in vascular surgery- a sub-study of the POISE-3 randomized clinical trial, European Heart Journal, Volume 45, Issue Supplement_1, October 2024 https://doi.org/10.1093/eurheartj/ehae666.3114
  16. Intraoperative cell salvage Carroll, C. et al. BJA Education, Volume 21, Issue 3, 95 – 101
  17. Current practice. Tools and resources Detecting, managing and monitoring haemostasis: viscoelastometric point of care testing (ROTEM, TEG and Sonoclot systems)  NICE https://www.nice.org.uk/guidance/dg13
  18. Martin C, Velissaris D, Rea K, et al. Tranexamic acid in vascular surgery: a randomized trial of efficacy and safety. Ann Surg. 2018;268(4):558-565.
  19. Haahr SM, Løvgreen NK, Alstrup JM, et al. Tranexamic acid in major non-cardiac surgery: a systematic review of efficacy and safety. Br J Anaesth. 2020;124(3):345-354.
  20. Murphy PM, Palumbo JA, Joseph PK, et al. The role of tranexamic acid in surgical blood loss reduction: a review of current evidence. Br J Surg. 2017;104(3):314-322.
  21. Grant DR, Graham RL, Ross SF, et al. Patient blood management in vascular surgery: the role of tranexamic acid and other pharmacological agents. Vasc Surg. 2017;35(6):548-556.