Can tranexamic acid be administered intraoperatively to a patient with a history of percutaneous transluminal coronary angioplasty (PTCA)?

Tranexamic Acid Can Be Safely Administered Intraoperatively to Patients with a History of PTCA

Tranexamic acid should be given intraoperatively to patients with a history of PTCA using standard dosing (1g IV over 10 minutes, followed by 1g infusion over 8 hours for procedures exceeding 2-3 hours), as high-quality evidence demonstrates no increased risk of myocardial infarction or thrombotic complications in patients with coronary artery disease. 1, 2

Evidence-Based Safety Profile in Coronary Artery Disease

The most compelling evidence comes from a large retrospective analysis of 26,808 patients with coronary artery disease or coronary stents who received TXA during total joint arthroplasty, which found zero postoperative myocardial infarctions and no significant increase in venous thromboembolism rates (0.29% vs 0.76%; p=0.09) compared to controls. 1 This directly addresses your patient population with prior PTCA.

The ATACAS trial, a large randomized controlled trial of 4,631 patients undergoing coronary artery surgery, demonstrated that tranexamic acid did not increase the composite outcome of death and thrombotic complications (16.7% vs 18.1%; relative risk 0.92,95% CI 0.81-1.05) while significantly reducing bleeding requiring reoperation (1.4% vs 2.8%; p=0.001). 2

Standard Dosing Protocol

• Loading dose: 1g IV over 10 minutes at the start of surgery, prior to incision 3, 4
• Maintenance infusion: 1g over 8 hours for procedures expected to exceed 2-3 hours 3, 4
• Timing consideration: Administer within 3 hours of bleeding onset if treating active hemorrhage for maximum efficacy 3

Critical Safety Considerations Specific to Post-PTCA Patients

Antiplatelet management is the primary concern, not TXA itself. ACC/AHA guidelines emphasize that patients on dual antiplatelet therapy (aspirin and clopidogrel) after PTCA require careful timing of surgery relative to stent placement. 5

Timing Algorithm Based on Stent Type:

• Bare-metal stent: Wait 4-6 weeks after placement, continue aspirin perioperatively 5
• Drug-eluting stent: Ideally delay surgery 12 months; if surgery required between 1-12 months, consider bare-metal stent strategy instead 5
• Balloon angioplasty only: Can proceed 14-29 days after procedure 5

For urgent/emergent surgery in patients on dual antiplatelet therapy: ACC/AHA guidelines specifically recommend tranexamic acid (along with aminocaproic acid) as part of a comprehensive hemostatic approach, noting that "early clinical experience suggested that the intraoperative use of tranexamic acid may permit surgery to be conducted safely on patients presenting while taking aspirin and clopidogrel." 5

Key Advantage Over Alternative Antifibrinolytics

Tranexamic acid has a superior safety profile compared to aprotinin in cardiac surgery patients. While aprotinin was associated with doubled risk of renal failure, 55% increased risk of MI/heart failure, and 181% increased risk of stroke, neither tranexamic acid nor aminocaproic acid was associated with increased risk of renal, cardiac, or cerebral events. 5 A subsequent study found aprotinin associated with reduced long-term survival (20.8% vs 12.7% 5-year mortality), an effect not seen with tranexamic acid. 5

Important Caveats and Contraindications

• Seizure risk: Tranexamic acid increases seizure risk (0.7% vs 0.1%; p=0.002), particularly at higher doses 2
• Renal impairment: Requires dose adjustment as TXA is renally excreted and accumulates in renal failure 3, 4
• Active intravascular clotting/DIC: Absolute contraindication 3, 6
• Timing window: Administration after 3 hours of bleeding onset may paradoxically increase bleeding death risk 3

Clinical Implementation for Your Patient

1. Verify stent timing: Confirm when PTCA was performed and whether stents were placed (and type) 5
2. Assess antiplatelet status: Determine current aspirin/clopidogrel use 5
3. Check renal function: Calculate creatinine clearance for dose adjustment if needed 3, 4
4. Administer standard TXA dosing: 1g IV over 10 minutes at surgical start 3, 1
5. Continue aspirin perioperatively if patient is beyond appropriate waiting period post-stent 5

The evidence strongly supports TXA use in this population, with the primary surgical risk related to antiplatelet management timing rather than TXA administration itself. 5, 1, 2