Aortoiliac Thrombosis Following Tranexamic Acid Administration During Urgent Cesarean Hysterectomy: A Case Report

Tranexamic acid as an adjunct to resuscitative endovascular balloon occlusion of the aorta does not worsen outcomes in a porcine model of hemorrhage

Background

Non-compressible torso hemorrhage (NCTH) represents a leading cause of preventable mortality in trauma. Resuscitative endovascular balloon occlusion of the aorta (REBOA) stabilizes NCTH but may predispose patients to thrombus generation. REBOA must therefore be prospectively evaluated for coagulation risks with concomitant usage of anti-fibrinolytic tranexamic acid (TXA). Using a porcine model of hemorrhage, it was hypothesized that TXA with REBOA would worsen coagulation outcomes and organ damage.

Materials and methods

Thirty-two male Yorkshire swine underwent 30% blood volume hemorrhage with randomization to vehicle control (VC; normal saline), VC+REBOA, TXA, or TXA+REBOA. At T0, animals received 10 mL/minute of group-specific infusion (GSI) followed at T10 by 500 mL of whole blood (WB), second GSI at 13 mL/hour, and Zone 1 REBOA inflation in REBOA groups. At T40, REBOA was deflated, with additional 500 mL WB, and continuation of GSI for 3 hours. Physiological, coagulation, and inflammatory parameters were measured throughout the protocol, with postmortem histopathology.

Results

After REBOA deflation at T40, lactate was significantly higher for the REBOA groups versus the non-REBOA groups, and pH, bicarbonate, and base excess were all significantly lower than the non-REBOA groups. There were no significant differences observed between groups in coagulation, inflammatory, metabolic, or histopathologic parameters.

Conclusions

Administration of TXA with REBOA did not cause more deleterious coagulation outcomes. All significant changes were expected results of REBOA ischemia, and not attributable to TXA treatment. This suggests NCTH can safely be treated with both hemorrhage control methods without exacerbating clotting outcomes.

Level of evidence

Not applicable-basic animal research.

Use of Tranexamic Acid With Resuscitative Endovascular Balloon Occlusion of the Aorta is Associated With Higher Distal Embolism Rates: Results From the American Association of Surgery for Trauma Aortic Occlusion and Resuscitation for Trauma and Acute Care Surgery Trial

INTRODUCTION

Tranexamic acid (TXA) use has been associated with thrombotic complications.

OBJECTIVE

We aim to investigate outcomes associated with TXA use in the setting of high- (HP) and low-profile (LP) introducer sheaths for resuscitative endovascular balloon occlusion of the aorta (REBOA).

PARTICIPANTS

The Aortic Occlusion and Resuscitation for Trauma and Acute Care Surgery (AORTA) database was queried for patients who underwent REBOA using a low-profile 7 French (LP) or high-profile, 11-14 French (HP) introducer sheaths between 2013 and 2022. Demographics, physiology, and outcomes were examined for patients who survived beyond the index operation.

RESULTS

574 patients underwent REBOA (503 LP, 71 HP); 77% were male, mean age was 44 ± 19 and mean injury severity score (ISS) was 35 ± 16. 212 patients received TXA (181 [36%] LP, 31 [43.7%] HP). There were no significant differences in admission vital signs, GCS, age, ISS, SBP at AO, CPR at AO, and duration of AO among LP and HP patients. Overall, mortality was significantly higher in the HP (67.6%) vs the LP group (54.9%; P = .043). Distal embolism was significantly higher in the HP group (20.4%) vs the LP group (3.9%; P < .001). Logistic regression demonstrated that TXA use was associated with a higher rate of distal embolism in both groups (OR = 2.92; P = .021). 2 LP patients (one who received TXA) required an amputation.

CONCLUSION

Patients who undergo REBOA are profoundly injured and physiologically devastated. Tranexamic acid was associated with a higher rate of distal embolism in those who received REBOA, regardless of access sheath size. For patients receiving TXA, REBOA placement should be accompanied by strict protocols for immediate diagnosis and treatment of thrombotic complications.

Management of large paravaginal hematomas with the Zhukovsky vaginal catheter

OBJECTIVE

To ameliorate the treatment of large paravaginal hematomas postpartum using the Zhukovsky vaginal catheter.

METHODS

A retrospective, controlled study including puerperas with large paravaginal hematomas. To assess the effectiveness of the proposed treatment, a group of patients underwent traditional obstetric surgery. A second group of puerperas underwent an integrated approach: the surgical stage (pararectal incision) and the application of the Zhukovsky vaginal catheter. The effectiveness of treatment was assessed according to the following criteria: blood loss volume and hospital admission time.

RESULTS

In total, 30 puerperas were included in the study; 15 in each treatment group. Large paravaginal hematomas were reported most often in primiparas (50.0%), in 36.7% were combined with rupture of the vagina and the cervix, and in 10.0% of cases an episiotomy was performed during delivery. In 40.0% of primiparas, the blood loss volume was more than 1000 mL, whereas in multiparous and in multiple pregnancies, blood loss did not exceed 1000 mL (r = -0.49; P = 0.022). In 25.0% of puerperas with a blood loss of up to 1000 mL there were no obstetric injuries; in the group with a blood loss of more than 1000 mL, 83.3% of patients had obstetric injuries. An integrated approach reduced the blood loss volume (r = -0.22; P = 0.29), compared with the traditional surgery, and reduced the hospital admission time from 12 (11.5; 13.5) days to 9 (7.5; 10.0) days (P < 0.001).

CONCLUSION

In patients with large paravaginal hematomas treated by an integrated approach we reported a decrease in bleeding, less risk of postoperative complications, and a reduction in the time of the hospital stay.

Tranexamic acid for the prevention and treatment of bleeding in surgery, trauma and bleeding disorders: a narrative review

OBJECTIVES

We review the evidence for tranexamic acid (TXA) for the treatment and prevention of bleeding caused by surgery, trauma and bleeding disorders. We highlight therapeutic areas where evidence is lacking and discuss safety issues, particularly the concern regarding thrombotic complications.

METHODS

An electronic search was performed in PubMed and the Cochrane Library to identify clinical trials, safety reports and review articles.

FINDINGS

TXA reduces bleeding in patients with menorrhagia, and in patients undergoing caesarian section, myomectomy, hysterectomy, orthopedic surgery, cardiac surgery, orthognathic surgery, rhinoplasty, and prostate surgery. For dental extractions in patients with bleeding disorders or taking antithrombotic drugs, as well as in cases of idiopathic epistaxis, tonsillectomy, liver transplantation and resection, nephrolithotomy, skin cancer surgery, burn wounds and skin grafting, there is moderate evidence that TXA is effective for reducing bleeding. TXA was not effective in reducing bleeding in traumatic brain injury and upper and lower gastrointestinal bleeding. TXA reduces mortality in patients suffering from trauma and postpartum hemorrhage. For many of these indications, there is no consensus about the optimal TXA dose. With certain dosages and with certain indications TXA can cause harm, such as an increased risk of seizures after high TXA doses with brain injury and cardiac surgery, and an increased mortality after delayed administration of TXA for trauma events or postpartum hemorrhage. Whereas most trials did not signal an increased risk for thrombotic events, some trials reported an increased rate of thrombotic complications with the use of TXA for gastro-intestinal bleeding and trauma.

CONCLUSIONS

TXA has well-documented beneficial effects in many clinical indications. Identifying these indications and the optimal dose and timing to minimize risk of seizures or thromboembolic events is work in progress.

Thromboelastographic Assessment of Fibrinolytic Activity in Postpartum Hemorrhage: A Retrospective Single-Center Observational Study

BACKGROUND

Postpartum hemorrhage is a leading cause of maternal mortality. Antifibrinolytic therapy has the potential to influence outcomes in postpartum hemorrhage, but the incidence of elevated fibrinolytic activity in postpartum hemorrhage is unknown.

METHODS

We retrospectively reviewed thromboelastography (TEG) results obtained for postpartum hemorrhage from 118 deliveries at The University of Chicago. TEG results were obtained as part of our postpartum hemorrhage protocol when blood loss exceeded 500 mL after vaginal delivery or 1000 mL after cesarean delivery. Our primary outcome was the incidence of elevated fibrinolytic activity, which we predefined as clot lysis ≥3% at 30 minutes (Ly30) on kaolin TEG. Platelet-mediated clot retraction can also lead to an elevated Ly30 on kaolin TEG. Therefore, to distinguish between fibrinolysis and clot retraction, we evaluated clot lysis using functional fibrinogen TEG, which contains a platelet inhibitor. We considered a kaolin TEG Ly30 ≥3% in conjunction with a nonzero functional fibrinogen TEG Ly30 suggestive of elevated fibrinolytic activity. We also recorded quantitative blood loss, primary etiology of hemorrhage, standard laboratory measurements of coagulation, and demographic and obstetric characteristics of the study population.

RESULTS

The median kaolin TEG Ly30 was 0.2% (interquartile range: 0%-0.8%). Fifteen of 118 women (12.7%; 95% confidence interval, 7.9%-19.9%) had kaolin TEG Ly30 values ≥3%. Of 15 patients with elevated Ly30 values, functional fibrinogen TEG Ly30 was available for 13, of which none demonstrated detectable clot lysis.

CONCLUSIONS

Our observation that none of the patients in our sample with kaolin TEG Ly30 values ≥3% had a nonzero functional fibrinogen TEG Ly30 value suggests that the observed elevations in kaolin TEG Ly30 may have been secondary to platelet-mediated clot retraction as opposed to fibrinolysis. Platelet-mediated clot retraction should be distinguished from fibrinolysis when assayed using viscoelastic techniques in postpartum hemorrhage. Further research is necessary to determine the optimal methods to assess fibrinolytic activity in postpartum hemorrhage.

Resuscitative Endovascular Balloon Occlusion of the Aorta and Concomitant Tranexamic Acid for Cesarean Hysterectomy Complicated by Common Femoral Artery Thrombosis: A Case Report

With increasing cesarean delivery rates, placenta accreta spectrum (PAS) disorders are occurring more frequently and represent a significant cause of peripartum hemorrhage. Different modalities have been explored to control blood loss during cesarean hysterectomies for PAS disorders, including administration of tranexamic acid (TXA) and balloon occlusion strategies. We present a case of a cesarean hysterectomy for a placenta percreta with the use of TXA and arterial balloon occlusion complicated by a lower extremity arterial thrombus requiring emergent thrombectomy. The outcome of this case suggests using caution with concomitant use of TXA and arterial balloon occlusion.

Ulnar Artery Thrombosis Following Tranexamic Acid Administration for Craniosynostosis Repair

Pediatric craniosynostosis repair with cranial vault reconstructive surgery can be associated with significant blood loss. Tranexamic acid (TXA), an antifibrinolytic agent, has been shown to decrease blood loss and transfusion volume in craniofacial surgery. Nonetheless data regarding the safety of TXA remains limited. The authors describe a case of ulnar artery thrombosis following ulnar arterial line placement in a patient who received TXA for cranial vault reconstructive surgery.

Primary lower limb joint replacement and tranexamic acid: an observational cohort study

Background

This work aimed to evaluate the efficacy and safety of routine tranexamic acid (TXA) use in elective orthopaedic lower limb joint replacement surgery.

Methods

This retrospective cohort study included all primary hip or knee replacement procedures by a single surgeon over a 6-year period. TXA was introduced during the study period as part of an enhanced recovery after surgery strategy.

Results

Of the 673 procedures, 446 cases (66.3%) received TXA. The median length of stay was 5 days (2-69) and 6 days (3-28) for the TXA and control groups, respectively (P < .001). Blood transfusion was required for 28 (6.3%) of the TXA cases versus 40 (17.6%) controls (P < .001). Complication rates were similar irrespective of TXA status. At multivariate analysis, TXA was significantly and independently associated with fewer blood transfusions (hazard ratio 0.309, 95% confidence interval: 0.168-0.568, P < .001), with a number needed to treat of 9 cases. TXA use was estimated to save between £67.89 and £155.90 per case.

Conclusions

Routine prophylactic TXA administration for elective primary hip and knee replacement reduces the likelihood of postoperative transfusion with a number needed to treat of 9. Cost savings may be as high as £155.90 per case, and no safety concerns were noted.