Perioperative Tranexamic Acid for ACTH-Secreting Pituitary Adenomas: Technical Note and Preliminary Cohort Study

Introduction: Endoscopic endonasal resection of ACTH-secreting pituitary adenoma has become a standard care, with resultant good surgical and endocrinologic outcomes. However, surgical intervention can be challenging due to elevated blood pressure, as well as direct cortisol impacts on endothelial cells and vascular permeability—resulting in excess surgical hemorrhage and elevated total blood loss. Tranexamic acid (TXA) is well characterized to promote intraoperative hemostasis and reduce surgical blood loss; however, whether it may provide any benefit in endonasal resection of ACTH-secreting pituitary adenoma is unstudied.

Methods: Criteria for preoperative TXA were defined by age, medical history, and key risk factors (Table 1). Descriptive statistical analysis reported for all sequential patients undergoing perioperative TXA treatment. Subjective surgeon's impressions of TXA efficacy were recorded postoperatively.

Results: A total of 25 patients met inclusion criteria and underwent perioperative administration of TXA, using a standardized dosing protocol of a 10 mg/kg bolus given over 30 minutes prior to incision, followed by maintenance infusion of 2 mg/kg per hour for the duration of the procedure. No incidence of myocardial infarction, postoperative DVT/PE, or other thromboembolic event was noted. One patient presented with acute pancreatitis on POD 3, which resolved following routine medical management. Subjective survey data indicated satisfaction with the patient selection protocol, and meaningful reduction in the degree of intraoperative bleeding, with improvement in >75% of cases, and no difference noted in the remainder.

Conclusion: Perioperative TXA represents a potentially efficacious approach for reduction of intraoperative blood loss during endoscopic endonasal surgery for ACTH-secreting tumors. Careful preoperative patient selection is emphasized, given the potential for thromboembolic complications; however, initial experience with our institutional protocol suggests a favorable risk/benefit profile when this treatment is applied judiciously in the recommended algorithm. Further study is required, ideally in a randomized, controlled trial setting.

Table 1 Criteria for perioperative TXA administration
Inclusions	Exclusions
ACTH-secreting pituitary adenoma	Age >50
Endoscopic endonasal resection	Hx DVT/PE
	Hx MI/CHF
	Insulin-dependent diabetes mellitus
	Medical indication for anticoagulation
	Other moderate/severe organ dysfunction

Publication History

Article published online:
12 February 2021