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Effects of Tranexamic Acid on Complications in Limb Reconstruction in War Trauma
Jennifer Sabino, MD, Kerry Latham, MD, Thomas Chung, DO, Mark Shashikant, MD, Robert Howard, MD, Patrick Basile, MD, Barry Martin, MD, Ian Valerio, MD.
Walter Reed National Military Medical Center, Bethesda, MD, USA.

Introduction: Tranexamic acid (TXA) is an antifibrinolytic that competitively inhibits the activation of plasminogen to plasmin, and it has been used to reduce blood loss in certain trauma, orthopedic, cardiovascular, and obstetrics/gynecological surgical cases where excessive blood loss is anticipated or encountered. Recently, the CRASH-2 trial showed that administration of TXA reduced the risk of death from bleeding in trauma patients. In recent years, the military has adapted TXA’s use in severely injured patients treated for massive blood losses within Iraq and Afghanistan combat hospitals. The purpose of this study is to determine the potential effect of TXA on the rates of venous thromboembolic events (VTEs) and flap related thrombosis events in those combat trauma patients who have undergone flap transfers for extremity reconstruction.
Methods:  A retrospective review of injured Servicemembers treated for extremity injuries from 2003 through 2012 at Walter Reed National Military Medical Center was completed. Data collected included patient demographics, flap types, and administration of TXA. Outcomes measured included DVT and PE rates as well as flap complications such as hematoma, venous congestion, thrombosis, and flap failure rates in our non-TXA and TXA cohorts..
Results: From 2003-2012, a total of 173 extremity flap procedures were performed (100 pedicle, 73 free flaps). TXA was used in 11% of all patients reviewed in this study, although the rate of TXA use has trended up with approximately 25% of patients treated since 2010 having received TXA. The rate of venous thromboembolic event (VTE) in this population was 23.7%. There were no patients who received TXA during initial resuscitation who went on to develop deep venous thrombosis or pulmonary embolus. Patients who did not receive TXA had a perioperative VTE rate of 26.6%. Thus, the use of TXA was not associated with increased risk of VTE (p = 0.008). TXA use did not significantly increase the rate of total flap complications (26%) or flap failure (5%) in patients undergoing flap procedure.
TXANo TXA
n (%)n (%)P-value
Total5 (26)33 (21)0.571
Infection0 (0)7 (5)0.608
Hematoma3 (16)12 (8)0.217
Venous congestion0 (0)2 (1)1.000
Partial necrosis1 (5)5 (3)0.508
Total necrosis1 (5)2 (1)0.296
Flap Failure1 (5)6 (4)0.564

Conclusion:  Improvements in initial resuscitation after combat trauma has resulted in improved survival and more patients presenting for complex limb salvage at tertiary medical facilities. Given the increasing use of TXA in the combat casualty trauma patient, potential concern over its pro-clotting functions and its impact on thrombosis rates as well as possible flap transfer complications such as flap thrombosis and failure is of interest. However, in this early review, the use of TXA was not associated with increased perioperative VTEs or with increased flap related complications. Further research with larger study numbers are indicated to better determine the significance and the effect of TXA on other aspects of flap transfers and/or complex limb salvages.


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