Oral Versus Intravenous Tranexamic Acid in Off-Pump Coronary Artery Bypass Surgery

Official title

Oral Versus Intravenous Tranexamic Acid for Blood Loss Prevention in Off-Pump Coronary Artery Bypass Surgery: A Randomized Double-Blind Non-Inferiority Trial

Overview

Tranexamic acid is commonly administered intravenously during cardiac surgery to reduce perioperative bleeding. Oral tranexamic acid may offer a simpler and less costly alternative, but its effectiveness in patients undergoing off-pump coronary artery bypass grafting has not been adequately established. TRANSCAB is a randomized, double-blind, parallel-group, non-inferiority clinical trial comparing oral and intravenous tranexamic acid in adults undergoing elective off-pump coronary artery bypass grafting. Participants will receive either oral tranexamic acid before surgery with an intravenous placebo at induction, or oral placebo before surgery with intravenous tranexamic acid at induction. The primary objective is to determine whether oral tranexamic acid is non-inferior to intravenous tranexamic acid for reducing postoperative blood loss. Secondary objectives include comparing transfusion requirements, postoperative hemoglobin levels, reoperation for bleeding, thromboembolic complications, seizures, acute kidney injury, and other postoperative outcomes.

Detailed description

Perioperative bleeding remains an important complication of coronary artery bypass surgery and may lead to blood transfusion, reoperation, prolonged hospitalization, and increased postoperative morbidity. Tranexamic acid is an antifibrinolytic drug widely used in cardiac surgery to reduce bleeding and transfusion requirements. It is most commonly administered intravenously, although oral administration may provide adequate systemic exposure while simplifying drug preparation and administration.

TRANSCAB is a monocentric, prospective, randomized, double-blind, placebo-controlled, parallel-group, non-inferiority trial conducted in adult patients undergoing elective off-pump coronary artery bypass grafting.

A total of 160 participants will be randomized in a 1:1 ratio to one of two treatment groups:

1. Oral tranexamic acid group: four 500 mg tranexamic acid tablets administered approximately 2 hours before surgical incision, together with an intravenous placebo administered at induction or incision according to the study protocol. 2. Intravenous tranexamic acid group: four matching oral placebo tablets administered approximately 2 hours before surgical incision, together with 1 g intravenous tranexamic acid administered at induction or incision according to the study protocol.

Participants, clinicians involved in perioperative management, outcome assessors, and investigators will remain blinded to treatment allocation. Study treatments will be prepared and dispensed according to the randomization list by the hospital pharmacy.

The primary objective is to assess whether oral tranexamic acid is non-inferior to intravenous tranexamic acid in reducing postoperative blood loss following off-pump coronary artery bypass grafting.

Secondary and safety outcomes will assess perioperative transfusion requirements, postoperative hemoglobin changes, clinically significant bleeding, reoperation for bleeding, thromboembolic events, seizures, acute kidney injury, mortality, duration of intensive care and hospital stay, and other postoperative complications specified in the protocol.

Interventions

• Drug Oral tranexamic acid
  Tranexamic acid, 2 g orally, administered as four 500 mg tablets approximately 2 hours before surgical incision.
• Drug Exacyl®
  Tranexamic acid, 1 g intravenously, diluted in 0.9% sodium chloride to a total volume of 50 mL and administered at induction or incision according to the study protocol.
• Drug Intravenous placebo
  Intravenous placebo consisting of 50 mL of 0.9% sodium chloride, administered at induction or incision according to the study protocol.

Primary outcome measures

• Cumulative Chest Tube Blood Loss Within 24 Hours After Surgery (mL) [Time frame: From completion of surgery to 24 hours postoperatively]

Secondary outcome measures (9)

• Number of Participants Receiving Red Blood Cell Transfusion [Time frame: From surgery until hospital discharge, up to 30 days]
• Hemoglobin Concentration at 24 Hours After Surgery (g/dL) [Time frame: At 24 hours after surgery]
• Number of Participants Requiring Reoperation for Bleeding [Time frame: During the index hospitalization, up to 30 days]
• Number of Participants With Thromboembolic Events [Time frame: From study intervention until 30 days after surgery]
• Number of Participants With Postoperative Seizures [Time frame: During the index hospitalization, up to 30 days]
• Number of Participants With Acute Kidney Injury According to Kidney Disease: Improving Global Outcomes (KDIGO) Criteria [Time frame: Within 7 days after surgery or until hospital discharge, whichever occurs first]
• Number of Participants With All-Cause Mortality Within 30 Days After Surgery [Time frame: Within 30 days after surgery]
• Length of Intensive Care Unit Stay (days) [Time frame: From intensive care unit admission until discharge from the intensive care unit, up to 30 days]
• Length of Hospital Stay (days) [Time frame: From the date of surgery until hospital discharge, up to 30 days]

Eligibility criteria

Inclusion criteria

• Age 18 years or older.
• Elective isolated coronary artery bypass grafting planned without cardiopulmonary bypass, including off-pump coronary artery bypass through sternotomy or minimally invasive/direct or totally endoscopic coronary artery bypass surgery. Conversion to cardiopulmonary bypass is permitted if clinically required.
• Perioperative tranexamic acid planned as part of routine care, with the participant eligible for both oral and intravenous administration according to the applicable product information and local policy.
• Written informed consent obtained before randomization.
• Routine preoperative laboratory results available, including at least hemoglobin and serum creatinine measured within 30 days before surgery.
• Available for in-hospital follow-up and Day 30 assessment.

Exclusion criteria

• Emergency surgery, non-isolated cardiac surgery, or planned on-pump coronary artery bypass grafting.
• Inability to provide informed consent or comply with the required follow-up.
• Hypersensitivity to tranexamic acid or any excipient of the study products.
• Contraindication or clinically relevant precaution to tranexamic acid according to the applicable product information, including:

• active arterial or venous thromboembolic disease or active intravascular clotting;
• history of subarachnoid hemorrhage;
• acquired defective color vision;
• clinically relevant seizure disorder or previous tranexamic-acid-associated seizure;
• disseminated intravascular coagulation without predominant hyperfibrinolysis;
• active upper urinary tract hematuria with a risk of ureteric obstruction.
• Renal function incompatible with the fixed protocol dose, including estimated glomerular filtration rate below 30 mL/min/1.73 m² or dialysis.
• Contraindication to either administration route, including inability to swallow tablets, malabsorption precluding oral dosing, or inability to obtain intravenous access.
• Pregnancy or breastfeeding.
• Participation in another interventional clinical trial that could interfere with study outcomes or safety.
• Planned use of another antifibrinolytic agent outside the protocol, including aprotinin or epsilon-aminocaproic acid.
• Any new clinical condition identified after randomization but before dosing that, in the investigator's judgment, makes administration of the study treatment unsafe.
• Uncontrolled hemodynamic or respiratory instability before administration of the study intervention.

Criteria are shown verbatim from the registry (in English). Final eligibility is always assessed by the study center.

Healthy volunteers: No

Study design

Allocation

Randomized

Model

Parallel assignment

Masking

Quadruple blind

Primary purpose

Prevention

Study locations

Belgium · 1 center

• Clinique Saint-Luc — Bouge

Identifiers

NCT: NCT07740330 · TRANSCAB · 2026-526581-24-01

Primary sources (government registries)

• ClinicalTrials.gov (US NIH)

View this study on ClinicalTrials.gov ↗