Yet Another Tranexamic Acid-Related Thrombotic Complication.

Abstract

To the Editor: We recently read with great interest the case presented by Liu et al regarding an episode of acute airway obstruction associated with tranexamic acid (TXA) administration during pneumonectomy.1Liu PH, Chen YT, Chen WH, et al: Acute airway obstruction in the nonoperated lung following intravenous administration of tranexamic acid during pneumonectomy. J Cardiothorac Vasc Anesth. [Epub ahead of print]Google Scholar TXA often is described as a low-risk antifibrinolytic agent when used in the perioperative period, and the large Clinical Randomisation of an Antifibrinolytic in Significant Haemorrhage 2 (CRASH-2) study demonstrated no increase in thrombotic events in a limited trauma population.2Williams-Johnson J.A. McDonald A.H. Strachan G.G. et al.Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2) A randomised, placebo-controlled trial.West Indian Med J. 2010; 59: 612-624PubMed Google Scholar Currently, no robust or large prospective trials have examined the thrombotic risks of TXA as a specific safety outcome. The majority of the literature concerning the safety of TXA is retrospective or underpowered to detect thrombotic-related complications. The case by Liu et al adds to the growing number of cases of perioperative thrombotic complications associated with TXA use, including one recently published by our group.3Gerstein NS, Brierley JK, Culling MD: Left ventricle thrombus after tranexamic acid for spine surgery in an HIV positive patient. Spine J. [Epub ahead of print]Google Scholar, 4Upadhyay S.P. Mallick P.N. Jagia M. et al.Acute arterial thrombosis associated with inadvertent high dose of tranexamic acid. Indian J.Crit Care Med. 2013; 17: 237-239Google Scholar, 5Taparia M. Cordingley F.T. Leahy M.F. Pulmonary embolism associated with tranexamic acid in severe acquired haemophilia.Eur J Haematol. 2002; 68: 307-309Crossref PubMed Scopus (56) Google Scholar, 6Gupta P.N. Mullamalla U.R. Sabin P. et al.Acute MI in a young hypertensive woman: Could it be due to tranexamic acid?.BMJ Case Rep. 2013; 2013Google Scholar TXA use generally (and erroneously) is believed to be a benign intervention that results in decreased blood loss in noncardiac surgery, particularly in orthopedic surgery. Much of the literature regarding TXA featured patients who were otherwise healthy and without significant thrombotic risk factors. Patients with any family history of thrombotic disease or risk factors for thrombosis frequently were excluded from TXA trials.7Gillette B.P. DeSimone L.J. Trousdale R.T. et al.Low risk of thromboembolic complications with tranexamic acid after primary total hip and knee arthroplasty.Clin Orthop Relat Res. 2013; 471: 150-154Crossref PubMed Scopus (150) Google Scholar, 8Dyba J. Chan F.C.F. Lau K.K. et al.Tranexamic acid is a weak provoking factor for thromboembolic events: A systematic review of the literature.Blood. 2013; 122: 3629Google Scholar As TXA use in noncardiac surgery continues to expand, it is incumbent on perioperative physicians to be fully cognizant of the thrombotic potential of TXA. Even though retrospective analysis has not shown a link between TXA and thromboembolic events, there has not been a large, prospective, randomized, controlled trial powered to detect differences in the rates of thrombotic events. This issue may be clarified somewhat by the forthcoming Aspirin and Tranexamic Acid for Coronary Artery Surgery (ATACAS) trial, which began in 2006 and still is ongoing.9Myles P.S. Smith J. Knight J. et al.Aspirin and Tranexamic Acid for Coronary Artery Surgery (ATACAS) Trial: Rationale and design.Am Heart J. 2008; 155: 224-230Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar ATACAS will specifically address the use of TXA in patients at high risk for thrombosis. The case presented by Liu et al was of particular interest because it was a very uncommon manifestation of a TXA-incited thrombotic event in a patient. Moreover, their patient had an advanced malignancy, which may have contributed to the background thrombotic risk. Until the thrombotic risks of TXA use in noncardiac surgery are delineated more clearly, its administration to any given patient should first prompt a thorough assessment for possible pre-existing hypercoagulable or thrombotic risks, and the ultimate use of TXA should be tempered if the aforementioned risks are extant. At our institution we have significantly heightened our level of scrutiny as to which patients are appropriate candidates to receive TXA for noncardiac surgery.