Is Tranexamic Acid Safe in Total Knee Replacement Surgery in Patients with Coronary Artery Disease?
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Published:
Oct 24, 2022
Keywords:
tranexamic acid, total knee arthroplasty, coronary disease
Main Article Content
Abstract
Introduction: Tranexamic acid (TXA) reduces blood loss and need for a transfusion after total knee arthroplasty (TKA). However, patients with a history of coronary artery (CA) stent placement might be at increased risk for thromboembolic complications.
Materials and Methods: We performed a retrospective analysis of patients with a history of coronary stenting who had undergone primary and revision TKA and received preoperative TXA. A comparison was made with a group of patients without coronary stenting. The presence of any clinical or electrocardiographic changes of acute coronary occlusion, thromboembolic events (TEE), blood transfusion, and pre- and postoperative hemoglobin levels were analyzed.
Results: 57 patients underwent 59 TKA surgeries (56 primary and 3 revisions) with a history of coronary stenting at least 1 year before arthroplasty. One patient presented symptoms of acute coronary syndrome and electrocardiogram (ECG) changes. There were no differences in the number of thromboembolic events. Only 1 patient received red blood cell transfusion in the control group. Relative bleeding was lower in the coronary group regardless of chronic use of aspirin and clopidogrel before surgery (2.09 vs 3.06 in the control group; p=0.01). In high-risk patients, TXA was not associated with higher TEEs.
Conclusions: Although TXA seemed safe and effective in this database review of patients with previous placement of CAS; a larger prospective trial is warranted to confirm these results.
Materials and Methods: We performed a retrospective analysis of patients with a history of coronary stenting who had undergone primary and revision TKA and received preoperative TXA. A comparison was made with a group of patients without coronary stenting. The presence of any clinical or electrocardiographic changes of acute coronary occlusion, thromboembolic events (TEE), blood transfusion, and pre- and postoperative hemoglobin levels were analyzed.
Results: 57 patients underwent 59 TKA surgeries (56 primary and 3 revisions) with a history of coronary stenting at least 1 year before arthroplasty. One patient presented symptoms of acute coronary syndrome and electrocardiogram (ECG) changes. There were no differences in the number of thromboembolic events. Only 1 patient received red blood cell transfusion in the control group. Relative bleeding was lower in the coronary group regardless of chronic use of aspirin and clopidogrel before surgery (2.09 vs 3.06 in the control group; p=0.01). In high-risk patients, TXA was not associated with higher TEEs.
Conclusions: Although TXA seemed safe and effective in this database review of patients with previous placement of CAS; a larger prospective trial is warranted to confirm these results.
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How to Cite
Costantini, J., Esteves, T. A., Nicolino, T. I., Carbó, L., & Costa Paz, M. (2022). Is Tranexamic Acid Safe in Total Knee Replacement Surgery in Patients with Coronary Artery Disease?. Revista De La Asociación Argentina De Ortopedia Y Traumatología, 87(5), 660-666. https://doi.org/10.15417/issn.1852-7434.2022.87.5.1602
Section
Clinical Research
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https://doi.org/10.1016/j.arth.2018.03.031
11. Sabbag OD, Abdel MP, Amundson AW, Larson DR, Pagnano MW. Tranexamic acid was safe in arthroplasty patients with a history of venous thromboembolism: A matched outcome study. J Arthroplasty 2017;32(9S):S246-50. https://doi.org/10.1016/j.arth.2017.02.008
12. Poeran J, Rasul R, Suzuki S, Danninger T, Mazumdar M, Opperer M, et al. Tranexamic acid use and postoperative outcomes in patients undergoing total hip or knee arthroplasty in the United States: retrospective analysis of effectiveness and safety. BMJ 2014;349:g4829. https://doi.org/10.1136/bmj.g4829
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haemorrhage (CRASH-2): a randomised, placebo controlled trial. Lancet 2010;376(9734):23-32. https://doi.org/10.1016/S0140-6736(10)60835-5
14. Duncan CM, Gillette BP, Jacob AK, Sierra RJ, Sanchez-Sotelo J, Smith HM. Venous thromboembolism and
mortality associated with tranexamic acid use during total hip and knee arthroplasty. J Arthroplasty 2015;30(2):272-6. https://doi.org/10.1016/j.arth.2014.08.022
15. Maniar RN, Kumar G, Singhi T, Nayak RM, Maniar PR. Most effective regimen of tranexamic acid in knee
arthroplasty: a prospective randomized controlled study in 240 patients. Clin Orthop Relat Res 2012;470(9):2605-
12. https://doi.org/10.1007/s11999-012-2310-y
16. Jules-Elysee KM, Tseng A, Sculco TP, Baaklini LR, McLawhorn AS, Pickard AJ, et al. Comparison of topical
and intravenous tranexamic acid for total knee replacement: a randomized double blinded controlled study of
effects on tranexamic acid levels and thrombogenic and inflammatory marker levels. J Bone Joint Surg Am
2019;101(23):2120-8. https://doi.org/10.2106/JBJS.19.00258
17. Curtis GL, Newman JM, George J, Klika AK, Barsoum WK, Higuera CA. Perioperative outcomes and complications in patients with heart failure following total knee arthroplasty. J Arthroplasty 2018;33(1):36-40.
https://doi.org/10.1016/j.arth.2017.07.043
18. Menendez ME, Memtsoudis SG, Opperer M, Boettner F, Gonzalez Della Valle A. A nationwide analysis of risk
factors for in-hospital myocardial infarction after total joint arthroplasty. Int Orthop 2015;39(4):777-86.
https://doi.org/10.1007/s00264-014-2502-z
19. Gillette BP, DeSimone LJ, Trousdale RT, Pagnano MW, Sierra RJ. Low risk of thromboembolic complications with tranexamic acid after primary total hip and knee arthroplasty. Clin Orthop Relat Res 2013;471(1):150-4.
https://doi.org/10.1007/s11999-012-2488-z
20. Smilowitz NR, Beckman J, Sherman SE, Berger JS. Hospital readmission after perioperative acute myocardial
infarction associated with noncardiac surgery. Circulation 2018;137(22):2332-39. https://doi.org/10.1161/CIRCULATIONAHA.117.032086
21. Whiting DR, Gillette BP, Duncan C, Smith H, Pagnano MW, Sierra RJ. Preliminary results suggest tranexamic acid is safe and effective in arthroplasty patients with severe comorbidities. Clin Orthop Relat Res 2014;472(1):66-72. https://doi.org/10.1007/s11999-013-3134-0
22. Fillingham YA, Darrith B, Calkins TE, Abdel MP, Malkani AL, Schwarzkopf R, et al; Hip Society Research Group.
Mark Coventry Award: a multicentre randomized clinical trial of tranexamic acid in revision total knee arthroplasty: does the dosing regimen matter? Bone Joint J 2019;101-B(7_Supple_C):10-6. https://doi.org/10.1302/0301-620X.101B7.BJJ-2018-1451.R1
23. Fillingham YA, Ramkumar DB, Jevsevar DS, Yates AJ, Shores P, Mullen K, et al. The efficacy of tranexamic acid
in total knee arthroplasty: a network meta-analysis. J Arthroplasty 2018;33(10):3090-98.e1. https://doi.org/10.1016/j.arth.2018.04.043
24. Hong C, Zhu F, Du D, Pilgram TK, Sicard GA, Bae KT. Coronary artery calcification and risk factors for
atherosclerosis in patients with venous thromboembolism. Atherosclerosis 2005;183(1):169-74.
https://doi.org/10.1016/j.atherosclerosis.2005.03.047
25. Zhou KD, Wang HY, Wang Y, Liu ZH, He C, Feng JM. Is topical or intravenous tranexamic acid preferred in total
hip arthroplasty? A randomized, controlled, noninferiority clinical trial. PLoS One 2018;13(10):e0204551.
https://doi.org/10.1371/journal.pone.0204551
26. Dauria A, Depetris H. Uso tópico de ácido tranexámico en el reemplazo total de rodilla primario. Rev Asoc Argent Ortop Traumatol 2018;83(1):5-11. https://doi.org/10.15417/697
2013;9(6):351-7. https://doi.org/10.1038/nrrheum.2013.27
2. Park JH, Rasouli MR, Mortazavi SMJ, Tokarski AT, Maltenfort MG, Parvizi J. Predictors of perioperative blood loss
in total joint arthroplasty. J Bone Joint Surg Am 2013;95(19):1777-83. https://doi.org/10.2106/JBJS.L.01335
3. Kalairajah Y, Simpson D, Cossey AJ, Verrall GM, Spriggins AJ. Blood loss after total knee replacement: effects of
computer-assisted surgery. J Bone Joint Surg Br 2005;87(11):1480-2. https://doi.org/10.1302/0301-620X.87B11.16474
4. Themistoklis T, Theodosia V, Konstantinos K, Georgios DI. Perioperative blood management strategies for patients undergoing total knee replacement: where do we stand now? World J Orthop 2017;8(6):441-54.
https://doi.org/10.5312/wjo.v8.i6.441
5. Wong J, Abrishami A, El Beheiry H, Mahomed NN, Roderick Davey J, Gandhi R, et al. Topical application of
tranexamic acid reduces postoperative blood loss in total knee arthroplasty: a randomized, controlled trial. J Bone Joint Surg Am 2010;92(15):2503-13. https://doi.org/10.2106/JBJS.I.01518
6. Stansfield R, Morris D, Jesulola E. The use of tranexamic acid (TXA) for the management of hemorrhage in
trauma patients in the prehospital environment: literature review and descriptive analysis of principal themes. Shock 2020;53(3):277-83. https://doi.org/10.1097/SHK.0000000000001389
7. Dai L, Bevan D, Rangarajan S, Sørensen B, Mitchell M. Stabilization of fibrin clots by activated prothrombin
complex concentrate and tranexamic acid in FVIII inhibitor plasma. Haemophilia 2011;17(5):e944-8. https://doi.org/10.1111/j.1365-2516.2011.02491.x
8. Fillingham YA, Ramkumar DB, Jevsevar DS, Yates AJ, Bini SA, Clarke HD, et al. Tranexamic acid in total
joint arthroplasty: the endorsed clinical practice guides of the American Association of Hip and Knee Surgeons,
American Society of Regional Anesthesia and Pain Medicine, American Academy of Orthopaedic Surgeons, Hip
Society, and Knee Society. Reg Anesth Pain Med 2019;44(1):7-11. https://doi.org/10.1136/rapm-2018-000024
9. Bidolegui FM, Pereira SP, Lugones A, Vindver GI. Ácido tranexámico endovenoso en el reemplazo total de rodilla sin manguito hemostático. Rev Asoc Argent Ortop Traumatol 2014;79(3):154-62. https://doi.org/10.15417/242
10. Fillingham YA, Ramkumar DB, Jevsevar DS, Yates AJ, Shores P, Mullen K, et al The safety of tranexamic acid in
total joint arthroplasty: a direct meta-analysis. J Arthroplasty 2018;33(10):3070-82.
https://doi.org/10.1016/j.arth.2018.03.031
11. Sabbag OD, Abdel MP, Amundson AW, Larson DR, Pagnano MW. Tranexamic acid was safe in arthroplasty patients with a history of venous thromboembolism: A matched outcome study. J Arthroplasty 2017;32(9S):S246-50. https://doi.org/10.1016/j.arth.2017.02.008
12. Poeran J, Rasul R, Suzuki S, Danninger T, Mazumdar M, Opperer M, et al. Tranexamic acid use and postoperative outcomes in patients undergoing total hip or knee arthroplasty in the United States: retrospective analysis of effectiveness and safety. BMJ 2014;349:g4829. https://doi.org/10.1136/bmj.g4829
13. CRASH-2 trial collaborators; Shakur H, Roberts I, Bautista R, Caballero J, Coats T, Dewan Y, 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. Lancet 2010;376(9734):23-32. https://doi.org/10.1016/S0140-6736(10)60835-5
14. Duncan CM, Gillette BP, Jacob AK, Sierra RJ, Sanchez-Sotelo J, Smith HM. Venous thromboembolism and
mortality associated with tranexamic acid use during total hip and knee arthroplasty. J Arthroplasty 2015;30(2):272-6. https://doi.org/10.1016/j.arth.2014.08.022
15. Maniar RN, Kumar G, Singhi T, Nayak RM, Maniar PR. Most effective regimen of tranexamic acid in knee
arthroplasty: a prospective randomized controlled study in 240 patients. Clin Orthop Relat Res 2012;470(9):2605-
12. https://doi.org/10.1007/s11999-012-2310-y
16. Jules-Elysee KM, Tseng A, Sculco TP, Baaklini LR, McLawhorn AS, Pickard AJ, et al. Comparison of topical
and intravenous tranexamic acid for total knee replacement: a randomized double blinded controlled study of
effects on tranexamic acid levels and thrombogenic and inflammatory marker levels. J Bone Joint Surg Am
2019;101(23):2120-8. https://doi.org/10.2106/JBJS.19.00258
17. Curtis GL, Newman JM, George J, Klika AK, Barsoum WK, Higuera CA. Perioperative outcomes and complications in patients with heart failure following total knee arthroplasty. J Arthroplasty 2018;33(1):36-40.
https://doi.org/10.1016/j.arth.2017.07.043
18. Menendez ME, Memtsoudis SG, Opperer M, Boettner F, Gonzalez Della Valle A. A nationwide analysis of risk
factors for in-hospital myocardial infarction after total joint arthroplasty. Int Orthop 2015;39(4):777-86.
https://doi.org/10.1007/s00264-014-2502-z
19. Gillette BP, DeSimone LJ, Trousdale RT, Pagnano MW, Sierra RJ. Low risk of thromboembolic complications with tranexamic acid after primary total hip and knee arthroplasty. Clin Orthop Relat Res 2013;471(1):150-4.
https://doi.org/10.1007/s11999-012-2488-z
20. Smilowitz NR, Beckman J, Sherman SE, Berger JS. Hospital readmission after perioperative acute myocardial
infarction associated with noncardiac surgery. Circulation 2018;137(22):2332-39. https://doi.org/10.1161/CIRCULATIONAHA.117.032086
21. Whiting DR, Gillette BP, Duncan C, Smith H, Pagnano MW, Sierra RJ. Preliminary results suggest tranexamic acid is safe and effective in arthroplasty patients with severe comorbidities. Clin Orthop Relat Res 2014;472(1):66-72. https://doi.org/10.1007/s11999-013-3134-0
22. Fillingham YA, Darrith B, Calkins TE, Abdel MP, Malkani AL, Schwarzkopf R, et al; Hip Society Research Group.
Mark Coventry Award: a multicentre randomized clinical trial of tranexamic acid in revision total knee arthroplasty: does the dosing regimen matter? Bone Joint J 2019;101-B(7_Supple_C):10-6. https://doi.org/10.1302/0301-620X.101B7.BJJ-2018-1451.R1
23. Fillingham YA, Ramkumar DB, Jevsevar DS, Yates AJ, Shores P, Mullen K, et al. The efficacy of tranexamic acid
in total knee arthroplasty: a network meta-analysis. J Arthroplasty 2018;33(10):3090-98.e1. https://doi.org/10.1016/j.arth.2018.04.043
24. Hong C, Zhu F, Du D, Pilgram TK, Sicard GA, Bae KT. Coronary artery calcification and risk factors for
atherosclerosis in patients with venous thromboembolism. Atherosclerosis 2005;183(1):169-74.
https://doi.org/10.1016/j.atherosclerosis.2005.03.047
25. Zhou KD, Wang HY, Wang Y, Liu ZH, He C, Feng JM. Is topical or intravenous tranexamic acid preferred in total
hip arthroplasty? A randomized, controlled, noninferiority clinical trial. PLoS One 2018;13(10):e0204551.
https://doi.org/10.1371/journal.pone.0204551
26. Dauria A, Depetris H. Uso tópico de ácido tranexámico en el reemplazo total de rodilla primario. Rev Asoc Argent Ortop Traumatol 2018;83(1):5-11. https://doi.org/10.15417/697