Does tranexamic acid increase the risk of thromboembolic events in immediate or delayed breast reconstruction? A review of the literature

  • Ian C. C. King
  • Andrew J. Mellington
  • Anita Hazari
  • Martin E. Jones
Original Paper



Tranexamic acid (TXA) is effective in reducing blood loss and minimizing transfusion requirements in acute trauma and in selected elective surgical procedures. Its utility within plastic surgery is presently limited. The role of TXA in both immediate and delayed breast reconstruction is contentious, with concerns centring on thromboembolic risk in oncological and microsurgical settings. We examined the current evidence for the safety and efficacy of TXA in breast surgery.


We searched PubMed, EMBASE and MEDLINE for studies in which TXA was used in breast surgery. The following terms were used: tranexamic acid, DVT (and deep vein/venous thrombosis), PE (and pulmonary embolus/emboli), mastectomy, mastopexy, breast augmentation, breast reconstruction, microsurgery/microsurgical and thromboembolic events/thromboembolus. All eligible studies were identified and full texts scrutinized.


Three papers were identified in which TXA was directly considered in relation to surgical procedures of the breast. None were related to breast reconstruction, either autologous or implant-based. Two papers studied mastectomy and TXA; one paper examined topical TXA use following mammoplasty. These studies demonstrated that TXA reduced or made no difference to haematoma incidence and might reduce drain outputs. Thromboembolic events were not discussed in any of the studies.


Studies examining the role of TXA in breast surgery are limited. There is currently no evidence to support concerns that using TXA in patients undergoing mastectomy and/or breast reconstruction is associated with an increased risk of thromboembolic events. There remains, however, a lack of level 1 evidence for TXA use in breast surgery, including reconstruction.

Level of Evidence: Not ratable.


Tranexamic acid Bleeding Breast reconstruction 


Compliance with ethical standards

Conflict of interest

Ian CC King, Andrew J. Mellington, Martin E. Jones and Anita Hazari declare that they have no conflicts of interest.

Ethical approval

For this type of study, formal consent is not required.

Informed consent


Patient consent

Patients provided written consent for the use of their images.


  1. 1.
    Goobie SM, Meier PM, Pereira LM, McGowan FX, Prescilla RP, Scharp LA, Rogers GF, Proctor MR, Meara JG, Soriano SG, Zurakowski D, Sethna NF (2011) Efficacy of tranexamic acid in pediatric craniosynostosis surgery: a double-blind, placebo-controlled trial. Anesthesiology 114:862–871CrossRefGoogle Scholar
  2. 2.
    Engel M, Bodem JP, Busch CJ, Horn D, Mertens C, Hoffmann J, Freudlsperger C (2015) The value of tranexamic acid during fronto-orbital advancement in isolated metopic craniosynostosis. J Craniomaxillofac Surg 43:1239–1243CrossRefGoogle Scholar
  3. 3.
    Murphy GR, Glass GE, Jain A (2016) The efficacy and safetyof tranexamic acid in cranio-maxillofacial and plastic surgery. J Craniofac Surg 27(2):374–379CrossRefGoogle Scholar
  4. 4.
    Oertil D, Laffer U, Haberthuer F, Kreuter U, Harder F (1994) Perioperative and postoperative tranexamic acid reduces wound complication rate after surgery for breast cancer. Br J Surg 81(6):856–859CrossRefGoogle Scholar
  5. 5.
    Wolder A, Scholz T, Pluto N, Diedrichson J, Arens-Landwehr A, Liebau J (2018) Subcutaneous mastectomy in female-to-male transsexuals: optimising perioperative and operative management in 8 years clinical experience. J Plast Reconstr Aesthet Surg 71(3):344–352CrossRefGoogle Scholar
  6. 6.
    Ausen K, Fossmark R, Spigset O, Pleym H (2015) Randomized clinical trial of topical tranexamic acid after reduction mammoplasty. Br J Surg 101(11):1348–1353CrossRefGoogle Scholar
  7. 7.
    Henry DA, Carless PA, Moxey AJ, O’Connell D, Stokes BJ, Fergusson DA et al (2011) Anti-fibrinolytic use for minimizing perioperative allogenic blood transfusion. Cochrane Database Syst Rev (3):CD001886Google Scholar
  8. 8.
    CRASH-2 Collaborators (2010) Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomized, placebo-controlled trial. Lancet 376:23–32CrossRefGoogle Scholar
  9. 9.
    CRASH-2 Collaborators (2011) The importance of early treatment with tranexamic acid in bleeding trauma patients: an exploratory analysis of the CRASH-2 randomised controlled trial. Lancet 377:1096–1101CrossRefGoogle Scholar
  10. 10.
    Luz L, Sankarankutty A, Passos E, Rizoli S, Fraga G, Nascimento B Jr (2012) Tranexamic acid for traumatic hemorrhage. Rev Col Bras Cir 39:77–80CrossRefGoogle Scholar
  11. 11.
    Roberts I, Perel P, Prieto-Merino D, Shakur H, Coats T, Hunt BJ, Lecky F, Brohi K, Willett K, on behalf of the CRASH-2 collaborators (2012) Effect of tranexamic acid on mortality in patients with traumatic bleeding: prespecified analysis of data from randomized controlled trial. BMJ. 345:e5839CrossRefPubMedCentralGoogle Scholar
  12. 12.
    Evaniew N, Bhandari M (2017) Cochrane in CORR: topical application of tranexamic acid for the reduction of bleeding (review). Clin Orthop Relat Res 475:21–26CrossRefGoogle Scholar
  13. 13.
    [No authors listed]. Tranexamic acid and thrombosis. Prescrire Int 2013; 22(140): 182–183Google Scholar
  14. 14.
    Dunn CJ, Goa KL (1999) Tranexamic acid: a review of its use in surgery and other indications. Drugs 57:1005–1032CrossRefGoogle Scholar
  15. 15.
    Godier A, Roberts A, Hunt BJ (2012) Tranexamic acid: less bleeding and less thrombosis? Crit Care 16(3):135CrossRefPubMedCentralGoogle Scholar
  16. 16.
    Salam A, King C, Orhan O, Mak V (2013) The great deception: tranexamic acid and extensive pulmonary emboli. BMJ Case Rep : 2013.
  17. 17.
    Ker K, Edwards P, Perel P, Shakur H, Roberts I (2012) Effect of tranexamic acid on surgical bleeding: systematic review and cumulative meta-analysis. BMJ 344:e3054CrossRefPubMedCentralGoogle Scholar
  18. 18.
    Ker K, Prieto-Merino D, Roberts I (2013) Systematic review, meta-analysis and metra-regression of the effect of tranexamic acid on surgical blood loss. Br J Surg 100:1271–1279CrossRefGoogle Scholar
  19. 19.
    Horrow JC, Van Riper DF, Strong MD, Grunewald KE, Parmet JL (1995) The dose-response relationship of tranexamic acid. Anesthesiology 82:383–392CrossRefGoogle Scholar
  20. 20.
    Poeran J, Rasul R, Suzuki S, Danninger T, Mazumdar M, Opperer M, Boettner F, Memtsoudis SG (2014) 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 349:g4829CrossRefPubMedCentralGoogle Scholar
  21. 21.
    Dowd NP, Karski JM, Cheng DC, Carroll JA, Lin Y, James RL, Butterworth J (2002) Phamocokinetics of tranexamic acid during cardiopulmonary bypass. Anesthesiology 97:390–399CrossRefGoogle Scholar
  22. 22.
    Ngaage DL, Bland (2010) Lesions from aprotinin L is the routine use and inconsistent dosing of tranexamic acid prudent? Meta-analysis of randomized and large matched observational studies. Eur J Cardiothorac Surg 37:1375–1383CrossRefGoogle Scholar
  23. 23.
    Murkin JM, Falter F, Franton J, Young B, Burt C, Chu M (2010) High-dose tranexamic acid is associated with nonischaemic clinical seizures in cardiac surgical patients. Anesth Analg 110:350–353CrossRefGoogle Scholar
  24. 24.
    Alshryda S, Sukeik M, Sarda P, Blenkinsopp J, Haddad FS, Mason JM (2014) A systematic review and meta-analysis of the topical administration of tranexamic acid in total hip and knee replacement. Bone Joint J 96-b:1005–1015CrossRefGoogle Scholar
  25. 25.
    Wind TC, Barfield WR, Moskal JT (2013) The effect of tranexamic acid on blood loss and transfusion rate in primary total knee arthroplasty. J Arthroplast 28:1080–1083CrossRefGoogle Scholar
  26. 26.
    WOMAN Trial Collaborators (2017) Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomized, double-blind, placebo-controlled trial. Lancet 389(10084):2105–2116CrossRefGoogle Scholar
  27. 27.
    Ali Shah MU, Asghar MI, Siddiqi R, Chaudri MS, Janjua AM, Iqbal A (2015) Topical application of tranexamic acid reduces postoperative bleeding in open-heart surgery: myth or fact? J Coll Physicians Surg Pak 25:161–165Google Scholar
  28. 28.
    Wang H, Shen B, Zeng Y (2014) Comparison of topical versus intravenous tranexamic in primary knee arthroplasty: a meta-analysis or randomized controlled and prospective cohort trials. Knee 21(6):987–993CrossRefGoogle Scholar
  29. 29.
    Shen PF, Hou WL, Chen JB, Wang B, Qu YX (2015 Feb) Effectiveness and safety of tranexamic acid for total knee arthoplasty: a prospective randomized control trial. Med Sci Monit 22(21):576–581CrossRefGoogle Scholar
  30. 30.
    Gillette BP, DeSimone LJ, Trousdale RT, Pagnano MW, Sierra RJ (2013) Low risk of thromboembolic complications with tranexamic acid after primary total hip and knee arthroplasty. Clin Orthop Relat Res 471(1):150–154CrossRefGoogle Scholar
  31. 31.
    Ker K, Roberts I (2014) Tranexamic acid for surgical bleeding. BMJ. 349:g4934CrossRefGoogle Scholar
  32. 32.
    Tygesen K, Alpert JS, Jaffe AS, Simoons ML, Chaitman BR, White HD (2012) Et al. third universal definition of myocardial infarction. J Am Coll Cardiol 60:1581–1598CrossRefGoogle Scholar
  33. 33.
    Roberts I (2013) Scientific letter: could tranexamic acid use in surgery reduce perioperative myocardial infarction? Heart 99:1785CrossRefGoogle Scholar
  34. 34.
    Myles PS, Smith JA, Painter T (2017) Tranexamic acid in patients undergoing coronary-artery surgery. N Engl J Med 376:1893CrossRefGoogle Scholar
  35. 35.
    Rohrich RJ, Cho MJ (2018) The role of tranexamic acid in plastic surgery: review and technical considerations. Plast Reconstr Surg 141(2):507–515CrossRefGoogle Scholar
  36. 36.
    Ker K, Beecher D, Roberts I (2013) Topical application of tranexamic acid for the reduction of bleeding. Cochrane Database Syst Rev 23(7):CD010562Google Scholar
  37. 37.
    Valerio IL, Campbell P, Sabino J, Lucas DJ, Jessie E, Rodriguez C, Fleming M (2015) TXA in combat casualty care—does it adversely affect extremity reconstruction and flap thrombosis rates? Mil Med 180(3 Suppl):24–28CrossRefGoogle Scholar
  38. 38.
    Montroy J, Fergusson NA, Hutton B, Lavallee LT, Morash C, Cagioannos I et al (2017) The safety and efficacy of lysine analogues in cancer patients: a systematic review and meta-analysis. Transfus Med Rev 31(3):141–148CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Queen Victoria HospitalEast GrinsteadUK

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