Influence of tranexamic acid use on venous thromboembolism risk in patients undergoing surgery for spine tumors

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  • 1 Department of Neurosurgery, Johns Hopkins University School of Medicine; and
  • | 2 Department of Pharmacy, Division of Critical Care and Surgery Pharmacy, Johns Hopkins Hospital, Baltimore, Maryland
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OBJECTIVE

Patients with spine tumors are at increased risk for both hemorrhage and venous thromboembolism (VTE). Tranexamic acid (TXA) has been advanced as a potential intervention to reduce intraoperative blood loss in this surgical population, but many fear it is associated with increased VTE risk due to the hypercoagulability noted in malignancy. In this study, the authors aimed to 1) develop a clinical calculator for postoperative VTE risk in the population with spine tumors, and 2) investigate the association of intraoperative TXA use and postoperative VTE.

METHODS

A retrospective data set from a comprehensive cancer center was reviewed for adult patients treated for vertebral column tumors. Data were collected on surgery performed, patient demographics and medical comorbidities, VTE prophylaxis measures, and TXA use. TXA use was classified as high-dose (≥ 20 mg/kg) or low-dose (< 20 mg/kg). The primary study outcome was VTE occurrence prior to discharge. Secondary outcomes were deep venous thrombosis (DVT) or pulmonary embolism (PE). Multivariable logistic regression was used to identify independent risk factors for VTE and the resultant model was deployed as a web-based calculator.

RESULTS

Three hundred fifty patients were included. The mean patient age was 57 years, 53% of patients were male, and 67% of surgeries were performed for spinal metastases. TXA use was not associated with increased VTE (14.3% vs 10.1%, p = 0.37). After multivariable analysis, VTE was independently predicted by lower serum albumin (odds ratio [OR] 0.42 per g/dl, 95% confidence interval [CI] 0.23–0.79, p = 0.007), larger mean corpuscular volume (OR 0.91 per fl, 95% CI 0.84–0.99, p = 0.035), and history of prior VTE (OR 2.60, 95% CI 1.53–4.40, p < 0.001). Longer surgery duration approached significance and was included in the final model. Although TXA was not independently associated with the primary outcome of VTE, high-dose TXA use was associated with increased odds of both DVT and PE. The VTE model showed a fair fit of the data with an area under the curve of 0.77.

CONCLUSIONS

In the present cohort of patients treated for vertebral column tumors, TXA was not associated with increased VTE risk, although high-dose TXA (≥ 20 mg/kg) was associated with increased odds of DVT or PE. Additionally, the web-based clinical calculator of VTE risk presented here may prove useful in counseling patients preoperatively about their individualized VTE risk.

ABBREVIATIONS

ASA = American Society of Anesthesiologists; ASIA = American Spinal Injury Association; AUC = area under the curve; CCI = Charlson Comorbidity Index; CI = confidence interval; DVT = deep venous thrombosis; IOBL = intraoperative blood loss; KPS = Karnofsky Performance Scale; LMWH = low-molecular-weight heparin; MCV = mean corpuscular volume; mFI-5 = modified 5-item Frailty Index; NIS = National Inpatient Sample; NSQIP = National Surgical Quality Improvement Program; OR = odds ratio; PE = pulmonary embolism; PRBC = packed red blood cells; ROC = receiver operating characteristic; SCD = sequential compression device; SIZE = Surgical Invasiveness; TXA = tranexamic acid; VTE = venous thromboembolism.

Images from Shimizu et al. (pp 616–623).

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