Bypass surgery in a Jehovah’s Witness with critical limb ischemia and end stage renal disease: a case report

A 60-year-old female Jehovah’s Witness with critical limb ischemia and end-stage renal disease underwent staged revascularization including endovascular intervention, free flap reconstruction, and ultimately femoropopliteal bypass using in situ great saphenous vein. Despite maximal blood conservation strategies—erythropoiesis-stimulating agents, intravenous iron, and albumin—her postoperative hemoglobin dropped to 4.7 g/dl without any evidence of active bleeding. She declined allogeneic transfusion and developed multiorgan failure, resulting in death on postoperative Day 3. This case highlights the clinical and ethical complexities of managing high-risk vascular patients who refuse blood transfusion, emphasizing the need for individualized risk assessment, careful perioperative planning, and consideration of patient autonomy under potential external influence.