Intravenous Tranexamic Acid is Associated with an Increased Incidence of Thromboembolic Events in High-Risk Patients

ABSTRACT

Study Design: Retrospective cohort study.

Objective: To evaluate the association between the use of intravenous tranexamic acid (TXA) and the incidence of thromboembolic events (TE) in high-risk patients undergoing major spine surgery.

Methods: A retrospective review of patients who underwent major spine surgery from 2015 to 2020 was conducted. Patients were classified as high-risk based on established criteria. The incidence of TE was compared between patients who received TXA and those who did not.

Results: A total of 113 patients met initial inclusion criteria, of which 16 received TXA and 97 did not receive TXA. There was no difference in the incidence of thromboembolic events between the TXA and no TXA groups (p=0.259). Analysis was conducted using Stata 17.0 (StataCorp, College Station, TX).

Conclusions: The use of TXA in high-risk patients undergoing major spine surgery does not appear to be associated with an increased incidence of thromboembolic events.

Keywords

Tranexamic acid, thromboembolic events, spine surgery, high-risk patients

INTRODUCTION

Tranexamic acid (TXA) is an antifibrinolytic agent that is effective in reducing perioperative blood loss in orthopedic surgery. Major spine surgery is often associated with significant perioperative blood loss and, as such, TXA can become a popular adjunctive to manage blood loss. Subsequently, TXA has been shown to reduce transfusion requirements and shorten hospital length of stay when used in spine surgery. However, use of TXA is not without several clinical considerations. As an antifibrinolytic, use of TXA raises concerns regarding increased risk of thrombotic events. This concern is particularly common in patients who may be more prone to thrombus such as those with pre-existing medical conditions (PE), deep venous thrombosis (DVT), and those undergoing major surgical procedures. Studies in other surgical fields have demonstrated a potential increased risk of thromboembolic events with the use of TXA, but the literature regarding its use in spine surgery remains limited.

METHODS

A retrospective review was conducted of patients who underwent major spine surgery at our institution from 2015 to 2020. Patients were classified as high-risk based on established criteria, including age, BMI, gender, smoking status, or ASA class before surgery and surgical characteristics. The TXA cohort included patients who received TXA intraoperatively, while the no TXA cohort included patients who did not receive TXA.

RESULTS

A total of 113 patients met initial inclusion criteria, of which 16 received TXA and 97 did not receive TXA. There was no difference in the incidence of thromboembolic events between the TXA and no TXA groups (p=0.259). Analysis was conducted using Stata 17.0 (StataCorp, College Station, TX).

DISCUSSION

Tranexamic acid has previously been demonstrated to be a safe and effective way to limit blood loss in spine surgery. However, the use of TXA in patients at high risk of thromboembolic events has recently come into question. This retrospective review of patients undergoing major spine surgery has demonstrated that the use of TXA does not appear to be associated with an increased risk of thromboembolic events. Our study has several limitations. First, we did not have data on the timing of perioperative anticoagulation agents. In addition, our retrospective analysis only included patients who underwent major spine surgery, and the use of lower extremity compression devices was not controlled for.

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