Association of preoperative antifibrinolytics with reduced blood transfusions after vascular surgery procedures.J Vasc Surg 2026 Apr 20. [Online ahead of print]JV
OBJECTIVE
Major vascular surgery interventions are critical for treating peripheral artery disease but carry a high risk of intraoperative blood loss with resultant coagulopathy. Blood product transfusions are limited, costly, and associated with an increased risk of myocardial infarction and death. Planned preoperative administration of antifibrinolytic agents (AFAs), aimed at inhibiting intraoperative plasmin-mediated lysis, has become a standard practice for orthopedic, trauma, obstetrics, and cardiac surgery, effectively reducing the perioperative bleeding and transfusion requirements. However, there are limited data that support AFA use in vascular surgery interventions. We hypothesize that preoperative AFA administration in elective major vascular surgical interventions is associated with reduced receipt of blood products.
METHODS
We included elective, index major abdominal revascularization procedures (open abdominal aortic aneurysm repair, mesenteric revascularization, and aortoiliac revascularization) and lower extremity revascularization procedures (open bypass) in adult patients across a multihospital health care system (January 2017-June 2024). Preoperative AFA use (tranexamic acid or epsilon-aminocaproic acid) was defined as administration within 60 minutes of the operative start time recorded in anesthesia logs. The primary outcome was total blood product transfusions received (packed red blood cells, fresh frozen plasma, platelets, or cryoprecipitate) within 5 postoperative days. Safety outcomes included inhospital seizures, venous thromboembolism events (VTEs; deep venous thrombosis, pulmonary embolism), arterial thrombosis (stroke, bypass thrombosis), and bleeding complications. Multivariable negative binomial regression was used to analyze the association between preoperative AFAs and the number of postoperative blood transfusions with clinically significant covariates selected a priori with variance clustering by surgeon.
RESULTS
Among 674 patients (aged 68.6 ± 10.8 years, male 67.4%, and White 88.1%), 213 (31.6%) received preoperative AFAs. Among treated patients, 36 (16.9%) received blood transfusion by postoperative day 5 at a median of 2 [IQR, 1-2] products per person. After covariate adjustment, preoperative AFA use was significantly associated with fewer blood products transfused by 5 postoperative days (adjusted incident rate ratios [aIRR], 0.57; 95% CI, 0.34-0.98; P =.04). Seizures were only observed among patients who did not receive preoperative AFAs (n = 2). Rates of VTE, bleeding complication, and bypass thrombosis were similar with and without AFA exposure (VTE: n = 2 [0.9%] vs n = 5 [1.1%]; P = .86; bleeding: n = 3 [1.4%] vs n = 6 [1.3%]; P > .9; bypass thrombosis: n = 7 [3.3%] vs n = 11 [2.4%]; P = .7). There were no inhospital strokes.
CONCLUSIONS
Overall, preoperative administration of AFAs was associated with a decreased number of transfusions at 5 postoperative days without notable safety concerns after major vascular interventions. These findings suggest a potential benefit of including preoperative AFA administration as the standard of care for patients undergoing major vascular surgery.
