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Administering TXA after TJA lowers overall frequency of VTE, but postoperative odds remain unchanged
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Patients who underwent total joint arthroplasty experienced a lower overall frequency of venothromboembolism and a trend toward reduced mortality with administration of tranexamic acid; however, the odds of postoperative venothromboembolism remained unchanged, according to study results.
Researchers retrospectively analyzed 13,262 elective total knee arthroplasty (TKA) or total hip arthroplasty (THA) procedures in 11,175 patients, among whom tranexamic acid (TXA) was administered intraoperatively in 21% of the procedures. The study’s primary outcome measure was the presence of clinically significant venothromboembolism (VTE) within 30 days of the date of surgery.
The researchers identified 196 VTE events, for which an overall frequency of 1.48% was calculated. Among the VTE events recorded, 37 occurred in 2,785 procedures where patients received TA and 159 VTE events occurred in 10,477 procedures where patients did not receive TXA.
Results showed significantly greater odds of VTE within 30 days among patients who underwent simultaneous bilateral surgery, primary joint arthroplasty, or TKA; patients with an American Society of Anesthesiology (ASA) grade of 3 to 5; and patients who received warfarin vs. low molecular weight heparin.
Within 30 days of surgery, the researchers identified 30 deaths from any cause, with the odds of death within 30 days significantly greater among men, those ages 70 years or older, those who underwent THA, and those with ASA grades 3 to 5.
According to univariate analysis, there was a sevenfold higher risk of death among patients who did not receive TXA vs. patients who received TXA. Results also showed the most frequent cause of death was cardiovascular event, followed by VTE, respiratory and other or unknown causes. – by Casey Tingle
Disclosures: Duncan reports no relevant financial disclosures. Please see the full study for a list of all other authors’ relevant financial disclosures.
Perspective
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Douglas A. Dennis, MD
Tranexamic acid is an anti-fibrinolytic agent most commonly use to lessen bleeding associated with major operative procedures such as joint replacement. The drug works via retarding fibrin degradation. The fear with use of this drug is the reduction in clot breakdown may increase the risk of venous thromboembolism, especially in high risk patients such as those with hypercoagulable states, previous venous thromboembolic disease, myocardial events, or stroke. Isolated reports of cerebral, pulmonary, mesenteric, and retinal thrombosis have been associated with the use of tranexamic acid. Reported warnings or contraindications to its use include hypersensitivity to the drug, presence or history thromboembolic disease, intracranial bleeding, hematuria, previous CVA, menorrhagia, or disseminated intravascular coagulation.
While numerous reports have documented the value of tranexamic acid use in reducing blood loss and transfusion rates, they’ve been underpowered to address the thromboembolic risk and mortality rates associated with use of this medication. All primary and revision hip and knee arthroplasty procedures performed at the Mayo Clinic over a five year period were evaluated (13,262 cases in 11,175 patients). Tranexamic acid was administered in 2,786 (21%) of the procedures. Subjects with high comorbidity risks such as vascular occlusive disease were not excluded from the study cohort. No statistical differences in 30-day venous thrombotic events or mortality rates were observed among those who received vs. those who did not receive tranexamic acid.
The weaknesses of this report include the fact that only 21% received tranexamic acid, the study was not randomized, and multiple different anti-coagulants were used for prophylaxis of deep venous thrombosis. These weaknesses are mitigated in part by the large cohort size and the fact that those with preoperative occlusive vascular disease were not excluded. This study suggests more widespread use of tranexamic acid can be considered, even in those previously considered high risk. Another alternative in the high risk patient is to consider use of this drug topically instead of parenterally.
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