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preserveAspectRatio="none"><path fill="none" stroke="#000" stroke-width="36" stroke-linecap="round" style="fill:#FFF" d="m320,350a153,153 0 1,0-2,2l170,170m-91-117 110,110-26,26-110-110"></path></svg></a><a id="jr-fip-done" class="wsprkl btn" title="Dismiss find">✘</a></nav><nav id="jr-fip-info-p"><a id="jr-fip-prev" class="wsprkl btn" title="Jump to previuos match">◀</a><button id="jr-fip-matches">no matches yet</button><a id="jr-fip-next" class="wsprkl btn" title="Jump to next match">▶</a></nav></nav></div><div id="jr-epub-interstitial" class="hidden"></div><div id="jr-content"><article data-type="main"><div class="main-content lit-style"><div class="fm-sec bkr_bottom_sep"><div class="bkr_thumb"><a href="https://www.nice.org.uk" title="National Institute for Health and Care Excellence (NICE)" class="img_link icnblk_img" ref="pagearea=logo&targetsite=external&targetcat=link&targettype=publisher"><img class="source-thumb" src="/corehtml/pmc/pmcgifs/bookshelf/thumbs/th-niceng156er19-lrg.png" alt="Cover of Use of tranexamic acid during transfer of people with ruptured or symptomatic abdominal aortic aneurysm" /></a></div><div class="bkr_bib"><h1 id="_NBK556906_"><span itemprop="name">Use of tranexamic acid during transfer of people with ruptured or symptomatic abdominal aortic aneurysm</span></h1><div class="subtitle">Abdominal aortic aneurysm: diagnosis and management</div><p><b>Evidence review R</b></p><p><i>NICE Guideline, No. 156</i></p><div class="half_rhythm">London: <a href="https://www.nice.org.uk" ref="pagearea=meta&targetsite=external&targetcat=link&targettype=publisher"><span itemprop="publisher">National Institute for Health and Care Excellence (NICE)</span></a>; <span itemprop="datePublished">2020 Mar</span>.<div class="small">ISBN-13: <span itemprop="isbn">978-1-4731-3452-2</span></div></div><div><a href="/books/about/copyright/">Copyright</a> © NICE 2020.</div></div><div class="bkr_clear"></div></div><div id="niceng156er19.s1"><h2 id="_niceng156er19_s1_">Use of tranexamic acid during transfer of people with ruptured or symptomatic abdominal aortic aneurysm</h2><div id="niceng156er19.s1.1"><h3>Review question</h3><p>Does tranexamic acid improve a person’s chance of survival or improve the stability of their condition in the transfer of people with ruptured or symptomatic abdominal aortic aneurysms to a regional vascular service?</p><div id="niceng156er19.s1.1.1"><h4>Introduction</h4><p>This review question aims to determine if tranexamic acid improves a person’s chance of survival or improve the stability of their condition in the transfer of people with ruptured or symptomatic abdominal aortic aneurysms to a regional vascular service.</p></div><div id="niceng156er19.s1.1.2"><h4>PICO table</h4></div><div id="niceng156er19.s1.1.3"><h4>Methods and process</h4><p>This evidence review was developed using the methods and process described in <a href="https://www.nice.org.uk/process/pmg20/chapter/introduction-and-overview" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Developing NICE guidelines: the manual</a>. Methods specific to this review question are described in the review protocol in <a href="#niceng156er19.appa">Appendix A</a>.</p><p>Declarations of interest were recorded according to NICE’s 2014 conflicts of interest policy.</p><p>A ‘bulk’ search was performed covering 2 review questions related to patient transfer. The database was sifted to identify all studies that met the criteria detailed in <a class="figpopup" href="/books/NBK556906/table/niceng156er19.tab1/?report=objectonly" target="object" rid-figpopup="figniceng156er19tab1" rid-ob="figobniceng156er19tab1">Table 1</a>. The relevant review protocol can be found in <a href="#niceng156er19.appa">Appendix A</a>.</p><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng156er19tab1"><a href="/books/NBK556906/table/niceng156er19.tab1/?report=objectonly" target="object" title="Table 1" class="img_link icnblk_img figpopup" rid-figpopup="figniceng156er19tab1" rid-ob="figobniceng156er19tab1"><img class="small-thumb" src="/books/NBK556906/table/niceng156er19.tab1/?report=thumb" src-large="/books/NBK556906/table/niceng156er19.tab1/?report=previmg" alt="Table 1. Inclusion criteria." /></a><div class="icnblk_cntnt"><h4 id="niceng156er19.tab1"><a href="/books/NBK556906/table/niceng156er19.tab1/?report=objectonly" target="object" rid-ob="figobniceng156er19tab1">Table 1</a></h4><p class="float-caption no_bottom_margin">Inclusion criteria. </p></div></div><p>Studies were considered for inclusion if they were randomised controlled trials, quasi-randomised controlled trials or systematic reviews (of the aforementioned study types) exploring the efficacy of tranexamic acid for improving survival of people with ruptured or symptomatic AAA who were being transferred to regional vascular services.</p><p>Studies were excluded if they:
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<ul><li class="half_rhythm"><div>were not in English</div></li><li class="half_rhythm"><div>were not full reports of the study (for example, published only as an abstract)</div></li><li class="half_rhythm"><div>were not peer-reviewed.</div></li></ul></p></div><div id="niceng156er19.s1.1.4"><h4>Clinical evidence</h4><div id="niceng156er19.s1.1.4.1"><h5>Included studies</h5><p>Initial literature searches identified 572 abstracts. Of these, no full texts were retrieved as potentially relevant. Thus, no studies were included as clinical evidence. An update search was conducted in December 2017, to identify any relevant studies published during guideline development. The search yielded 10 abstracts; all of which were not considered relevant to this review question. As a result no additional studies were included.</p></div><div id="niceng156er19.s1.1.4.2"><h5>Excluded studies</h5><p>No studies were retrieved for full-text review.</p></div></div><div id="niceng156er19.s1.1.5"><h4>Economic evidence</h4><div id="niceng156er19.s1.1.5.1"><h5>Included studies</h5><p>An initial literature search was conducted jointly for all review questions by applying standard health economic filters to a clinical search for AAA. This search returned a total of 5,173 citations. Following review of all titles and abstracts, no studies were identified as being potentially relevant to the review question. No full texts were retrieved, and no studies were included as economic evidence.</p><p>An update search was conducted in December 2017, to identify any relevant health economic analyses published during guideline development. The search yielded 814 abstracts; all of which were not considered relevant to this review question. As a result no additional studies were identified.</p></div><div id="niceng156er19.s1.1.5.2"><h5>Excluded studies</h5><p>No studies were retrieved for full-text review.</p></div></div><div id="niceng156er19.s1.1.6"><h4>Economic model</h4><p>This review question does not lend itself to economic evaluation, and was not prioritised by the committee for economic modelling. As such, no economic model was developed for this review question.</p></div><div id="niceng156er19.s1.1.7"><h4>Evidence statements</h4><p>No evidence was identified for this review question.</p><div id="niceng156er19.s1.1.7.1"><h5>Research recommendations</h5><p>RR9. Does tranexamic acid improve survival in people who are having repair (EVAR or open surgical repair) of a ruptured AAA?</p></div></div><div id="niceng156er19.s1.1.8"><h4>The committee’s discussion of the evidence</h4><div id="niceng156er19.s1.1.8.1"><h5>Interpreting the evidence</h5><div id="niceng156er19.s1.1.8.1.1"><h5>The outcomes that matter most</h5><p>The committee considered that the outcomes that matter most are perioperative morbidity and mortality. The committee considered that perioperative outcomes were more important than long-term outcomes because any benefits of tranexamic acid are likely to become apparent in the acute period.</p></div><div id="niceng156er19.s1.1.8.1.2"><h5>The quality of the evidence</h5><p>The committee were unable to make a clear judgement on the clinical utility of tranexamic acid as no evidence was identified from the literature searches. Furthermore, they were not aware of tranexamic acid routinely being used in people with ruptured AAA. In light of this, the committee agreed that research, in the form of well-conducted randomised controlled trials, was needed to determine whether tranexamic acid improves the chances of survival following aneurysm rupture.</p></div><div id="niceng156er19.s1.1.8.1.3"><h5>Benefits and harms</h5><p>The committee recognised that tranexamic acid is becoming increasingly used in people who are bleeding profusely after major trauma, and noted that clinical trials show some benefits of using tranexamic acid in this population. The committee agreed that it would not be appropriate to extrapolate the reported benefits in trauma patients to people with ruptured AAA because the 2 populations were inherently different:
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<ul><li class="half_rhythm"><div>The committee noted that it is easier to determine when people with major trauma have major bleeding events because their bleeding is likely to be visible. They agreed that it would be difficult to ascertain the presence of a ruptured AAA without imaging, and the administration of tranexamic acid based on a false-positive diagnosis could potentially cause harm.</div></li><li class="half_rhythm"><div>The committee noted that NICE’s trauma guideline (NICE NG39) recommends that tranexamic acid should not be administered more than 3 hours after injury in people with major trauma. The committee agreed that such a recommendation would not suit the context of AAA because of the inability to accurately determine the time of rupture.</div></li><li class="half_rhythm"><div>Finally, the committee noted that people with ruptured AAA are at risk of thrombotic complications (such as venous thromboembolism and myocardial infarction), and the prothrombotic effects of tranexamic acid may increase their risk of these events.</div></li></ul></p></div></div><div id="niceng156er19.s1.1.8.2"><h5>Cost effectiveness and resource use</h5><p>The committee noted that tranexamic acid is already used in practice to treat conditions other than AAA. Since the committee agreed that a lack of recommendations would have no impact in practice, they concluded that there would also be no impact on NHS costs and resources.</p></div><div id="niceng156er19.s1.1.8.3"><h5>Other factors the committee took into account</h5><p>No other factors were discussed by the committee.</p></div></div></div></div><div id="appendixesappgroup1"><h2 id="_appendixesappgroup1_">Appendices</h2><div id="niceng156er19.appa"><h3>Appendix A. Review protocols</h3><div id="niceng156er19.appa.s1"><h4>Review protocol for use of tranexamic acid during transfer of people with ruptured or symptomatic abdominal aortic aneurysm</h4><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng156er19appatab1"><a href="/books/NBK556906/table/niceng156er19.appa.tab1/?report=objectonly" target="object" title="Table" class="img_link icnblk_img figpopup" rid-figpopup="figniceng156er19appatab1" rid-ob="figobniceng156er19appatab1"><img class="small-thumb" src="/books/NBK556906/table/niceng156er19.appa.tab1/?report=thumb" src-large="/books/NBK556906/table/niceng156er19.appa.tab1/?report=previmg" alt="Image " /></a><div class="icnblk_cntnt"><h4 id="niceng156er19.appa.tab1"><a href="/books/NBK556906/table/niceng156er19.appa.tab1/?report=objectonly" target="object" rid-ob="figobniceng156er19appatab1">Table</a></h4><p class="float-caption no_bottom_margin">Systematic reviews of study designs listed below Randomised controlled trials</p></div></div></div></div><div id="niceng156er19.appb"><h3>Appendix B. Literature search strategies</h3><div id="niceng156er19.appb.s1"><h4>Clinical search literature search strategy</h4><div id="niceng156er19.appb.s1.1"><h5>Main searches</h5><p>Bibliographic databases searched for the guideline
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<ul><li class="half_rhythm"><div>Cumulative Index to Nursing and Allied Health Literature - CINAHL (EBSCO)</div></li><li class="half_rhythm"><div>Cochrane Database of Systematic Reviews – CDSR (Wiley)</div></li><li class="half_rhythm"><div>Cochrane Central Register of Controlled Trials – CENTRAL (Wiley)</div></li><li class="half_rhythm"><div>Database of Abstracts of Reviews of Effects – DARE (Wiley)</div></li><li class="half_rhythm"><div>Health Technology Assessment Database – HTA (Wiley)</div></li><li class="half_rhythm"><div>EMBASE (Ovid)</div></li><li class="half_rhythm"><div>MEDLINE (Ovid)</div></li><li class="half_rhythm"><div>MEDLINE Epub Ahead of Print (Ovid)</div></li><li class="half_rhythm"><div>MEDLINE In-Process (Ovid)</div></li></ul></p></div><div id="niceng156er19.appb.s1.2"><h5>Identification of evidence for review questions</h5><p>The searches were conducted between November 2015 and October 2017 for 31 review questions (RQ). In collaboration with Cochrane, the evidence for several review questions was identified by an update of an existing Cochrane review. Review questions in this category are indicated below. Where review questions had a broader scope, supplement searches were undertaken by NICE.</p><p>Searches were re-run in December 2017.</p><p>Where appropriate, study design filters (either designed in-house or by McMaster) were used to limit the retrieval to, for example, randomised controlled trials. Details of the study design filters used can be found in section 4.</p></div><div id="niceng156er19.appb.s1.3"><h5>Search strategy review question 20</h5><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng156er19appbtab1"><a href="/books/NBK556906/table/niceng156er19.appb.tab1/?report=objectonly" target="object" title="Table" class="img_link icnblk_img figpopup" rid-figpopup="figniceng156er19appbtab1" rid-ob="figobniceng156er19appbtab1"><img class="small-thumb" src="/books/NBK556906/table/niceng156er19.appb.tab1/?report=thumb" src-large="/books/NBK556906/table/niceng156er19.appb.tab1/?report=previmg" alt="Image " /></a><div class="icnblk_cntnt"><h4 id="niceng156er19.appb.tab1"><a href="/books/NBK556906/table/niceng156er19.appb.tab1/?report=objectonly" target="object" rid-ob="figobniceng156er19appbtab1">Table</a></h4><p class="float-caption no_bottom_margin">Medline Strategy, searched 4th October 2017 Database: Ovid MEDLINE(R) <1946 to September Week 3 2017></p></div></div></div></div><div id="niceng156er19.appb.s2"><h4>Health Economics literature search strategy</h4><div id="niceng156er19.appb.s2.1"><h5>Sources searched to identify economic evaluations</h5><ul><li class="half_rhythm"><div>NHS Economic Evaluation Database – NHS EED (Wiley) last updated Dec 2014</div></li><li class="half_rhythm"><div>Health Technology Assessment Database – HTA (Wiley) last updated Oct 2016</div></li><li class="half_rhythm"><div>Embase (Ovid)</div></li><li class="half_rhythm"><div>MEDLINE (Ovid)</div></li><li class="half_rhythm"><div>MEDLINE In-Process (Ovid)</div></li></ul><p>Search filters to retrieve economic evaluations and quality of life papers were appended to the population and intervention terms to identify relevant evidence. Searches were not undertaken for qualitative RQs. For social care topic questions additional terms were added. Searches were re-run in September 2017 where the filters were added to the population terms.</p></div><div id="niceng156er19.appb.s2.2"><h5>Health economics search strategy</h5><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng156er19appbtab2"><a href="/books/NBK556906/table/niceng156er19.appb.tab2/?report=objectonly" target="object" title="Table" class="img_link icnblk_img figpopup" rid-figpopup="figniceng156er19appbtab2" rid-ob="figobniceng156er19appbtab2"><img class="small-thumb" src="/books/NBK556906/table/niceng156er19.appb.tab2/?report=thumb" src-large="/books/NBK556906/table/niceng156er19.appb.tab2/?report=previmg" alt="Image " /></a><div class="icnblk_cntnt"><h4 id="niceng156er19.appb.tab2"><a href="/books/NBK556906/table/niceng156er19.appb.tab2/?report=objectonly" target="object" rid-ob="figobniceng156er19appbtab2">Table</a></h4></div></div></div></div></div><div id="niceng156er19.appc"><h3>Appendix C. Clinical evidence study selection</h3><div id="niceng156er19.appc.fig1" class="figure"><div class="graphic"><a href="/core/lw/2.0/html/tileshop_pmc/tileshop_pmc_inline.html?title=Image%20niceng156er19appcf1&p=BOOKS&id=556906_niceng156er19appcf1.jpg" target="tileshopwindow" class="inline_block pmc_inline_block ts_canvas img_link" title="Click on image to zoom"><div class="ts_bar small" title="Click on image to zoom"></div><img src="/books/NBK556906/bin/niceng156er19appcf1.jpg" alt="Image niceng156er19appcf1" class="tileshop" title="Click on image to zoom" /></a></div></div></div><div id="niceng156er19.appd"><h3>Appendix D. Economic evidence study selection</h3><div id="niceng156er19.appd.fig1" class="figure"><div class="graphic"><a href="/core/lw/2.0/html/tileshop_pmc/tileshop_pmc_inline.html?title=Image%20niceng156er19appdf1&p=BOOKS&id=556906_niceng156er19appdf1.jpg" target="tileshopwindow" class="inline_block pmc_inline_block ts_canvas img_link" title="Click on image to zoom"><div class="ts_bar small" title="Click on image to zoom"></div><img src="/books/NBK556906/bin/niceng156er19appdf1.jpg" alt="Image niceng156er19appdf1" class="tileshop" title="Click on image to zoom" /></a></div></div></div><div id="niceng156er19.appe"><h3>Appendix E. Excluded studies</h3><div id="niceng156er19.appe.s1"><h4>Clinical studies</h4><p>No full text papers were retrieved. All studies were excluded at review of titles and abstracts.</p></div><div id="niceng156er19.appe.s2"><h4>Economic studies</h4><p>No full text papers were retrieved. All studies were excluded at review of titles and abstracts.</p></div></div><div id="niceng156er19.appf"><h3>Appendix F. Research recommendations</h3><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng156er19appftab1"><a href="/books/NBK556906/table/niceng156er19.appf.tab1/?report=objectonly" target="object" title="Table" class="img_link icnblk_img figpopup" rid-figpopup="figniceng156er19appftab1" rid-ob="figobniceng156er19appftab1"><img class="small-thumb" src="/books/NBK556906/table/niceng156er19.appf.tab1/?report=thumb" src-large="/books/NBK556906/table/niceng156er19.appf.tab1/?report=previmg" alt="Image " /></a><div class="icnblk_cntnt"><h4 id="niceng156er19.appf.tab1"><a href="/books/NBK556906/table/niceng156er19.appf.tab1/?report=objectonly" target="object" rid-ob="figobniceng156er19appftab1">Table</a></h4><p class="float-caption no_bottom_margin">Perioperative morbidity and mortality Bleeding/need for transfusion</p></div></div><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng156er19appftab2"><a href="/books/NBK556906/table/niceng156er19.appf.tab2/?report=objectonly" target="object" title="Table" class="img_link icnblk_img figpopup" rid-figpopup="figniceng156er19appftab2" rid-ob="figobniceng156er19appftab2"><img class="small-thumb" src="/books/NBK556906/table/niceng156er19.appf.tab2/?report=thumb" src-large="/books/NBK556906/table/niceng156er19.appf.tab2/?report=previmg" alt="Image " /></a><div class="icnblk_cntnt"><h4 id="niceng156er19.appf.tab2"><a href="/books/NBK556906/table/niceng156er19.appf.tab2/?report=objectonly" target="object" rid-ob="figobniceng156er19appftab2">Table</a></h4></div></div></div><div id="niceng156er19.appg"><h3>Appendix G. Glossary</h3><dl><dt id="gl1_DL1_DI1">Abdominal Aortic Aneurysm (AAA)</dt><dd><p>A localised bulge in the abdominal aorta (the major blood vessel that supplies blood to the lower half of the body including the abdomen, pelvis and lower limbs) caused by weakening of the aortic wall. It is defined as an aortic diameter greater than 3 cm or a diameter more than 50% larger than the normal width of a healthy aorta. The clinical relevance of AAA is that the condition may lead to a life threatening rupture of the affected artery. Abdominal aortic aneurysms are generally characterised by their shape, size and cause:
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<ul><li class="half_rhythm"><div>Infrarenal AAA: an aneurysm located in the lower segment of the abdominal aorta below the kidneys.</div></li><li class="half_rhythm"><div>Juxtarenal AAA: a type of infrarenal aneurysm that extends to, and sometimes, includes the lower margin of renal artery origins.</div></li><li class="half_rhythm"><div>Suprarenal AAA: an aneurysm involving the aorta below the diaphragm and above the renal arteries involving some or all of the visceral aortic segment and hence the origins of the renal, superior mesenteric, and celiac arteries, it may extend down to the aortic bifurcation.</div></li></ul></p></dd><dt id="gl1_DL1_DI2">Abdominal compartment syndrome</dt><dd><p>Abdominal compartment syndrome occurs when the pressure within the abdominal cavity increases above 20 mm Hg (intra-abdominal hypertension). In the context of a ruptured AAA this is due to the mass effect of a volume of blood within or behind the abdominal cavity. The increased abdominal pressure reduces blood flow to abdominal organs and impairs pulmonary, cardiovascular, renal, and gastro-intestinal function. This can cause multiple organ dysfunction and eventually lead to death.</p></dd><dt id="gl1_DL1_DI3">Cardiopulmonary exercise testing</dt><dd><p>Cardiopulmonary Exercise Testing (CPET, sometimes also called CPX testing) is a non-invasive approach used to assess how the body performs before and during exercise. During CPET, the patient performs exercise on a stationary bicycle while breathing through a mouthpiece. Each breath is measured to assess the performance of the lungs and cardiovascular system. A heart tracing device (Electrocardiogram) will also record the hearts electrical activity before, during and after exercise.</p></dd><dt id="gl1_DL1_DI4">Device migration</dt><dd><p>Migration can occur after device implantation when there is any movement or displacement of a stent-graft from its original position relative to the aorta or renal arteries. The risk of migration increases with time and can result in the loss of device fixation. Device migration may not need further treatment but should be monitored as it can lead to complications such as aneurysm rupture or endoleak.</p></dd><dt id="gl1_DL1_DI5">Endoleak</dt><dd><p>An endoleak is the persistence of blood flow outside an endovascular stent - graft but within the aneurysm sac in which the graft is placed.
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<ul><li class="half_rhythm"><div>Type I – Perigraft (at the proximal or distal seal zones): This form of endoleak is caused by blood flowing into the aneurysm because of an incomplete or ineffective seal at either end of an endograft. The blood flow creates pressure within the sac and significantly increases the risk of sac enlargement and rupture. As a result, Type I endoleaks typically require urgent attention.</div></li><li class="half_rhythm"><div>Type II – Retrograde or collateral (mesenteric, lumbar, renal accessory): These endoleaks are the most common type of endoleak. They occur when blood bleeds into the sac from small side branches of the aorta. They are generally considered benign because they are usually at low pressure and tend to resolve spontaneously over time without any need for intervention. Treatment of the endoleak is indicated if the aneurysm sac continues to expand.</div></li><li class="half_rhythm"><div>Type III – Midgraft (fabric tear, graft dislocation, graft disintegration): These endoleaks occur when blood flows into the aneurysm sac through defects in the endograft (such as graft fractures, misaligned graft joints and holes in the graft fabric). Similarly to Type I endoleak, a Type III endoleak results in systemic blood pressure within the aneurysm sac that increases the risk of rupture. Therefore, Type III endoleaks typically require urgent attention.</div></li><li class="half_rhythm"><div>Type IV– Graft porosity: These endoleaks often occur soon after AAA repair and are associated with the porosity of certain graft materials. They are caused by blood flowing through the graft fabric into the aneurysm sac. They do not usually require treatment and tend to resolve within a few days of graft placement.</div></li><li class="half_rhythm"><div>Type V – Endotension: A Type V endoleak is a phenomenon in which there is continued sac expansion without radiographic evidence of a leak site. It is a poorly understood abnormality. One theory that it is caused by pulsation of the graft wall, with transmission of the pulse wave through the aneurysm sac to the native aneurysm wall. Alternatively it may be due to intermittent leaks which are not apparent at imaging. It can be difficult to identify and treat any cause.</div></li></ul></p></dd><dt id="gl1_DL1_DI6">Endovascular aneurysm repair</dt><dd><p>Endovascular aneurysm repair (EVAR) is a technique that involves placing a stent –graft prosthesis within an aneurysm. The stent-graft is inserted through a small incision in the femoral artery in the groin, then delivered to the site of the aneurysm using catheters and guidewires and placed in position under X-ray guidance.
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<ul><li class="half_rhythm"><div>Conventional EVAR refers to placement of an endovascular stent graft in an AAA where the anatomy of the aneurysm is such that the ‘instructions for use’ of that particular device are adhered to. Instructions for use define tolerances for AAA anatomy that the device manufacturer considers appropriate for that device. Common limitations on AAA anatomy are infrarenal neck length (usually >10mm), diameter (usually ≤30mm) and neck angle relative to the main body of the AAA</div></li><li class="half_rhythm"><div>Complex EVAR refers to a number of endovascular strategies that have been developed to address the challenges of aortic proximal neck fixation associated with complicated aneurysm anatomies like those seen in juxtarenal and suprarenal AAAs. These strategies include using conventional infrarenal aortic stent grafts outside their ‘instructions for use’, using physician-modified endografts, utilisation of customised fenestrated endografts, and employing snorkel or chimney approaches with parallel covered stents.</div></li></ul></p></dd><dt id="gl1_DL1_DI7">Goal directed therapy</dt><dd><p>Goal directed therapy refers to a method of fluid administration that relies on minimally invasive cardiac output monitoring to tailor fluid administration to a maximal cardiac output or other reliable markers of cardiac function such as stroke volume variation or pulse pressure variation.</p></dd><dt id="gl1_DL1_DI8">Post processing technique</dt><dd><p>For the purpose of this review, a post-processing technique refers to a software package that is used to augment imaging obtained from CT scans, (which are conventionally presented as axial images), to provide additional 2- or 3-dimensional imaging and data relating to an aneurysm’s, size, position and anatomy.</p></dd><dt id="gl1_DL1_DI9">Permissive hypotension</dt><dd><p>Permissive hypotension (also known as hypotensive resuscitation and restrictive volume resuscitation) is a method of fluid administration commonly used in people with haemorrhage after trauma. The basic principle of the technique is to maintain haemostasis (the stopping of blood flow) by keeping a person’s blood pressure within a lower than normal range. In theory, a lower blood pressure means that blood loss will be slower, and more easily controlled by the pressure of internal self-tamponade and clot formation.</p></dd><dt id="gl1_DL1_DI10">Remote ischemic preconditioning</dt><dd><p>Remote ischemic preconditioning is a procedure that aims to reduce damage (ischaemic injury) that may occur from a restriction in the blood supply to tissues during surgery. The technique aims to trigger the body’s natural protective functions. It is sometimes performed before surgery and involves repeated, temporary cessation of blood flow to a limb to create ischemia (lack of oxygen and glucose) in the tissue. In theory, this “conditioning” activates physiological pathways that render the heart muscle resistant to subsequent prolonged periods of ischaemia.</p></dd><dt id="gl1_DL1_DI11">Tranexamic acid</dt><dd><p>Tranexamic acid is an antifibrinolytic agent (medication that promotes blood clotting) that can be used to prevent, stop or reduce unwanted bleeding. It is often used to reduce the need for blood transfusion in adults having surgery, in trauma and in massive obstetric haemorrhage.</p></dd></dl></div></div></div><div class="fm-sec"><div><p>Final</p></div><div><p>Methods, evidence and recommendations</p><p>This evidence review was developed by the NICE Guideline Updates Team</p></div><div><p><b>Disclaimer:</b> The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.</p><p>Local commissioners and/or providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties.</p><p>NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the <a href="http://wales.gov.uk/" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Welsh Government</a>, <a href="http://www.scotland.gov.uk/" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Scottish Government</a>, and <a href="http://www.northernireland.gov.uk/" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Northern Ireland Executive</a>. All NICE guidance is subject to regular review and may be updated or withdrawn.</p></div><div class="half_rhythm"><a href="/books/about/copyright/">Copyright</a> © NICE 2020.</div><div class="small"><span class="label">Bookshelf ID: NBK556906</span><span class="label">PMID: <a href="https://pubmed.ncbi.nlm.nih.gov/32407020" title="PubMed record of this title" ref="pagearea=meta&targetsite=entrez&targetcat=link&targettype=pubmed">32407020</a></span></div></div><div class="small-screen-prev"></div><div class="small-screen-next"></div></article><article data-type="table-wrap" id="figobniceng156er19tab1"><div id="niceng156er19.tab1" class="table"><h3><span class="label">Table 1</span><span class="title">Inclusion criteria</span></h3><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK556906/table/niceng156er19.tab1/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng156er19.tab1_lrgtbl__"><table><thead><tr><th id="hd_h_niceng156er19.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Parameter</th><th id="hd_h_niceng156er19.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Inclusion criteria</th></tr></thead><tbody><tr><td headers="hd_h_niceng156er19.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Population</td><td headers="hd_h_niceng156er19.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">People with a suspected or confirmed ruptured or symptomatic unruptured abdominal aortic aneurysm who need to be transferred to a regional vascular service</td></tr><tr><td headers="hd_h_niceng156er19.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Intervention</td><td headers="hd_h_niceng156er19.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Tranexamic acid</td></tr><tr><td headers="hd_h_niceng156er19.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Comparator</td><td headers="hd_h_niceng156er19.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Placebo or no intervention</td></tr><tr><td headers="hd_h_niceng156er19.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Outcome</td><td headers="hd_h_niceng156er19.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<ul><li class="half_rhythm"><div>Survival /mortality</div></li><li class="half_rhythm"><div>Bleeding/need for transfusion</div></li><li class="half_rhythm"><div>Myocardial infarction</div></li><li class="half_rhythm"><div>Renal failure</div></li><li class="half_rhythm"><div>Adverse effects of intervention – stroke, acute limb ischaemia, venous thromboembolism</div></li><li class="half_rhythm"><div>Quality of life</div></li><li class="half_rhythm"><div>Resource use, including of intensive care unit stay, and cost</div></li></ul></td></tr></tbody></table></div></div></article><article data-type="table-wrap" id="figobniceng156er19appatab1"><div id="niceng156er19.appa.tab1" class="table"><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK556906/table/niceng156er19.appa.tab1/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng156er19.appa.tab1_lrgtbl__"><table><thead><tr><th id="hd_h_niceng156er19.appa.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:bottom;">Review question 20</th><th id="hd_h_niceng156er19.appa.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:bottom;">Does tranexamic acid improve a person’s chance of survival or improve the stability of their condition in the transfer of people with ruptured or symptomatic abdominal aortic aneurysms to a regional vascular service?</th></tr></thead><tbody><tr><td headers="hd_h_niceng156er19.appa.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Objectives</td><td headers="hd_h_niceng156er19.appa.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">To determine if tranexamic acid improves a person’s chance of survival or improve the stability of their condition in the transfer of people with ruptured or symptomatic abdominal aortic aneurysms to a regional vascular service</td></tr><tr><td headers="hd_h_niceng156er19.appa.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Type of review</td><td headers="hd_h_niceng156er19.appa.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Intervention</td></tr><tr><td headers="hd_h_niceng156er19.appa.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Language</td><td headers="hd_h_niceng156er19.appa.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">English only</td></tr><tr><td headers="hd_h_niceng156er19.appa.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Study design</td><td headers="hd_h_niceng156er19.appa.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>Systematic reviews of study designs listed below</p>
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<p>Randomised controlled trials</p>
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<p>Quasi-randomised controlled trials</p>
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</td></tr><tr><td headers="hd_h_niceng156er19.appa.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Status</td><td headers="hd_h_niceng156er19.appa.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>Published papers only (full text)</p>
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<p>No date restrictions</p>
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</td></tr><tr><td headers="hd_h_niceng156er19.appa.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Population</td><td headers="hd_h_niceng156er19.appa.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">People with a suspected or confirmed ruptured or symptomatic unruptured abdominal aortic aneurysm who need to be transferred to a regional vascular service</td></tr><tr><td headers="hd_h_niceng156er19.appa.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Intervention</td><td headers="hd_h_niceng156er19.appa.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Tranexamic acid</td></tr><tr><td headers="hd_h_niceng156er19.appa.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Comparator</td><td headers="hd_h_niceng156er19.appa.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Placebo or no intervention</td></tr><tr><td headers="hd_h_niceng156er19.appa.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Outcomes</td><td headers="hd_h_niceng156er19.appa.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>Survival /mortality</p>
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<p>Bleeding/need for transfusion</p>
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<p>Myocardial infarction</p>
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<p>Renal failure</p>
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<p>Adverse effects of intervention – stroke, acute limb ischaemia, venous thromboembolism</p>
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<p>Quality of life</p>
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<p>Resource use, including of intensive care unit stay, and cost</p>
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</td></tr><tr><td headers="hd_h_niceng156er19.appa.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Other criteria for inclusion / exclusion of studies</td><td headers="hd_h_niceng156er19.appa.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>Exclusion:</p>
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<p>Non-English language</p>
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<p>Abstract/non-published (i only)</p>
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</td></tr><tr><td headers="hd_h_niceng156er19.appa.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Baseline characteristics to be extracted in evidence tables</td><td headers="hd_h_niceng156er19.appa.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>Age</p>
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<p>Sex</p>
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<p>Size of aneurysm</p>
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<p>Comorbidities</p>
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</td></tr><tr><td headers="hd_h_niceng156er19.appa.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Search strategies</td><td headers="hd_h_niceng156er19.appa.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">See <a href="#niceng156er19.appb">Appendix B</a></td></tr><tr><td headers="hd_h_niceng156er19.appa.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Review strategies</td><td headers="hd_h_niceng156er19.appa.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>Appropriate NICE Methodology Checklists, depending on study designs, will be used as a guide to appraise the quality of individual studies.</p>
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<p>Data on all included studies will be extracted into evidence tables. Where statistically possible, a meta-analytic approach will be used to give an overall summary effect.</p>
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<p>All key findings from evidence will be presented in GRADE profiles and further summarised in evidence statements.</p>
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</td></tr><tr><td headers="hd_h_niceng156er19.appa.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Key papers</td><td headers="hd_h_niceng156er19.appa.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">None identified</td></tr></tbody></table></div></div></article><article data-type="table-wrap" id="figobniceng156er19appbtab1"><div id="niceng156er19.appb.tab1" class="table"><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK556906/table/niceng156er19.appb.tab1/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng156er19.appb.tab1_lrgtbl__"><table><thead><tr><th id="hd_h_niceng156er19.appb.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">
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<p>Medline Strategy, searched 4th October 2017</p>
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<p>Database: Ovid MEDLINE(R) <1946 to September Week 3 2017></p>
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<p>Search Strategy:</p>
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</th></tr></thead><tbody><tr><td headers="hd_h_niceng156er19.appb.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">1 Aortic Rupture/</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">2 RAAA.tw.</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">3 1 or 2</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">4 Aortic Aneurysm, Abdominal/</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">5 (Aneurysm* adj4 (abdom* or thoracoabdom* or thoraco-abdom* or aort* or spontan*)).tw.</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">6 ((juxtarenal* or juxta-renal* or juxta renal* or paraerenal* or para-renal* or para renal* or suprarenal* or supra renal* or supra-renal* or short neck* or short-neck* or shortneck* or visceral aortic segment*) adj4 aneur?sm*).tw.</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">7 AAA.tw.</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">8 or/4-7</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">9 (aort* adj4 (balloon* or dilat* or bulg* or expan*)).tw.</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">10 (ruptur* or tear* or bleed* or trauma* or burst* or large* or big*).tw.</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">11 symptom*.tw.</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">12 or/9-11</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">13 8 and 12</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">14 3 or 13</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">15 Patient transfer/</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">16 “Transportation of Patients”/</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">17 “continuity of patient care”/ or patient handoff/</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">18 ((clinical or patient* or intershift* or nurs* or physician* or shift or staff*) adj4 (handover* or hand-off or handoff or hand off)).tw.</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">19 (transition* adj4 care).tw.</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">20 og.fs.</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">21 Ambulances/</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">22 ambulance*.tw.</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">23 (emergency adj4 (unit* or vehicle* or paramedic* or transport* or transfer*)).tw.</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">24 ((transfer* or transport* or travel* or move* or moving or continuity or transition* or hando* or journey* or arriv*) adj4 (hospital* or intrahospital* or emergenc* or paramedic* or facilit* or “cardiothoracic unit*” or “vascular unit*” or “vascular centre*” or “vascular center*” or “vascular service*” or “endovascular unit*” or “specialist unit*” or “specialist centre*” or “specialist center*” or “specialist service*” or “endovascular centre*” or “endovascular center*” or “endovascular service*” or “primary care” or “secondary care” or “tertiary care” or “tertiary centre*” or “tertiary center*” or “referral centre*” or “referral center*” or centrali* or regionali*)).tw.</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">25 (patient* adj4 (transfer* or transport* or travel* or move* or moving or continuity or transition* or hando* or journey* or arriv*)).tw.</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">26 ((transfer* or transport* or travel* or transition* or hando* or journey* or arriv*) adj4 (quick* or delay* or slow* or fast* or speed* or time* or length* or duration or mode)).tw.</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">27 ((interfacilit* or inter facilit* or intrafacilit* or intra facilit* or inter hospital* or interhospital* or intrahospital* or intra hospital*) adj4 (transfer* or travel* or move* or moving)).tw.</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">28 Time-to-treatment/</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">29 “time to treatment”.tw.</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">30 “door to treatment”.tw.</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">31 antifibrinolytic agents/</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">32 (antifibrinoly* or antiplasmin*).tw.</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">33 ((plasmin or fibrinoly*) adj4 inhibitor*).tw.</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">34 Tranexamic Acid/</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">35 ((tranexam* or tranex-am* or tranex am* or tranexan* or tranex-an* or tranex an*) adj4 acid*).tw.</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">36 TXA.tw.</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">37 or/15-36</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">38 14 and 37</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">39 animals/ not humans/</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">40 38 not 39</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">41 limit 40 to english language</td></tr></tbody></table></div></div></article><article data-type="table-wrap" id="figobniceng156er19appbtab2"><div id="niceng156er19.appb.tab2" class="table"><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK556906/table/niceng156er19.appb.tab2/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng156er19.appb.tab2_lrgtbl__"><table><thead><tr><th id="hd_h_niceng156er19.appb.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Medline Strategy</th></tr></thead><tbody><tr><th headers="hd_h_niceng156er19.appb.tab2_1_1_1_1" id="hd_b_niceng156er19.appb.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Economic evaluations</th></tr><tr><td headers="hd_h_niceng156er19.appb.tab2_1_1_1_1 hd_b_niceng156er19.appb.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">1 Economics/</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab2_1_1_1_1 hd_b_niceng156er19.appb.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">2 exp “Costs and Cost Analysis”/</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab2_1_1_1_1 hd_b_niceng156er19.appb.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">3 Economics, Dental/</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab2_1_1_1_1 hd_b_niceng156er19.appb.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">4 exp Economics, Hospital/</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab2_1_1_1_1 hd_b_niceng156er19.appb.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">5 exp Economics, Medical/</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab2_1_1_1_1 hd_b_niceng156er19.appb.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">6 Economics, Nursing/</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab2_1_1_1_1 hd_b_niceng156er19.appb.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">7 Economics, Pharmaceutical/</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab2_1_1_1_1 hd_b_niceng156er19.appb.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">8 Budgets/</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab2_1_1_1_1 hd_b_niceng156er19.appb.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">9 exp Models, Economic/</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab2_1_1_1_1 hd_b_niceng156er19.appb.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">10 Markov Chains/</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab2_1_1_1_1 hd_b_niceng156er19.appb.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">11 Monte Carlo Method/</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab2_1_1_1_1 hd_b_niceng156er19.appb.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">12 Decision Trees/</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab2_1_1_1_1 hd_b_niceng156er19.appb.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">13 econom*.tw.</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab2_1_1_1_1 hd_b_niceng156er19.appb.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">14 cba.tw.</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab2_1_1_1_1 hd_b_niceng156er19.appb.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">15 cea.tw.</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab2_1_1_1_1 hd_b_niceng156er19.appb.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">16 cua.tw.</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab2_1_1_1_1 hd_b_niceng156er19.appb.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">17 markov*.tw.</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab2_1_1_1_1 hd_b_niceng156er19.appb.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">18 (monte adj carlo).tw.</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab2_1_1_1_1 hd_b_niceng156er19.appb.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">19 (decision adj3 (tree* or analys*)).tw.</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab2_1_1_1_1 hd_b_niceng156er19.appb.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">20 (cost or costs or costing* or costly or costed).tw.</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab2_1_1_1_1 hd_b_niceng156er19.appb.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">21 (price* or pricing*).tw.</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab2_1_1_1_1 hd_b_niceng156er19.appb.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">22 budget*.tw.</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab2_1_1_1_1 hd_b_niceng156er19.appb.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">23 expenditure*.tw.</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab2_1_1_1_1 hd_b_niceng156er19.appb.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">24 (value adj3 (money or monetary)).tw.</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab2_1_1_1_1 hd_b_niceng156er19.appb.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">25 (pharmacoeconomic* or (pharmaco adj economic*)).tw.</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab2_1_1_1_1 hd_b_niceng156er19.appb.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">26 or/1-25</td></tr><tr><th headers="hd_h_niceng156er19.appb.tab2_1_1_1_1" id="hd_b_niceng156er19.appb.tab2_1_1_28_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Quality of life</th></tr><tr><td headers="hd_h_niceng156er19.appb.tab2_1_1_1_1 hd_b_niceng156er19.appb.tab2_1_1_28_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">1 “Quality of Life”/</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab2_1_1_1_1 hd_b_niceng156er19.appb.tab2_1_1_28_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">2 quality of life.tw.</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab2_1_1_1_1 hd_b_niceng156er19.appb.tab2_1_1_28_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">3 “Value of Life”/</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab2_1_1_1_1 hd_b_niceng156er19.appb.tab2_1_1_28_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">4 Quality-Adjusted Life Years/</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab2_1_1_1_1 hd_b_niceng156er19.appb.tab2_1_1_28_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">5 quality adjusted life.tw.</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab2_1_1_1_1 hd_b_niceng156er19.appb.tab2_1_1_28_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">6 (qaly* or qald* or qale* or qtime*).tw.</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab2_1_1_1_1 hd_b_niceng156er19.appb.tab2_1_1_28_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">7 disability adjusted life.tw.</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab2_1_1_1_1 hd_b_niceng156er19.appb.tab2_1_1_28_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">8 daly*.tw.</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab2_1_1_1_1 hd_b_niceng156er19.appb.tab2_1_1_28_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">9 Health Status Indicators/</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab2_1_1_1_1 hd_b_niceng156er19.appb.tab2_1_1_28_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">10 (sf36 or sf 36 or short form 36 or shortform 36 or sf thirtysix or sf thirty six or shortform thirtysix or shortform thirty six or short form thirtysix or short form thirty six).tw.</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab2_1_1_1_1 hd_b_niceng156er19.appb.tab2_1_1_28_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">11 (sf6 or sf 6 or short form 6 or shortform 6 or sf six or sfsix or shortform six or short form six).tw.</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab2_1_1_1_1 hd_b_niceng156er19.appb.tab2_1_1_28_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">12 (sf12 or sf 12 or short form 12 or shortform 12 or sf twelve or sftwelve or shortform twelve or short form twelve).tw.</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab2_1_1_1_1 hd_b_niceng156er19.appb.tab2_1_1_28_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">13 (sf16 or sf 16 or short form 16 or shortform 16 or sf sixteen or sfsixteen or shortform sixteen or short form sixteen).tw.</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab2_1_1_1_1 hd_b_niceng156er19.appb.tab2_1_1_28_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">14 (sf20 or sf 20 or short form 20 or shortform 20 or sf twenty or sftwenty or shortform twenty or short form twenty).tw.</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab2_1_1_1_1 hd_b_niceng156er19.appb.tab2_1_1_28_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">15 (euroqol or euro qol or eq5d or eq 5d).tw.</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab2_1_1_1_1 hd_b_niceng156er19.appb.tab2_1_1_28_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">16 (qol or hql or hqol or hrqol).tw.</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab2_1_1_1_1 hd_b_niceng156er19.appb.tab2_1_1_28_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">17 (hye or hyes).tw.</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab2_1_1_1_1 hd_b_niceng156er19.appb.tab2_1_1_28_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">18 health* year* equivalent*.tw.</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab2_1_1_1_1 hd_b_niceng156er19.appb.tab2_1_1_28_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">19 utilit*.tw.</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab2_1_1_1_1 hd_b_niceng156er19.appb.tab2_1_1_28_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">20 (hui or hui1 or hui2 or hui3).tw.</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab2_1_1_1_1 hd_b_niceng156er19.appb.tab2_1_1_28_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">21 disutili*.tw.</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab2_1_1_1_1 hd_b_niceng156er19.appb.tab2_1_1_28_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">22 rosser.tw.</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab2_1_1_1_1 hd_b_niceng156er19.appb.tab2_1_1_28_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">23 quality of wellbeing.tw.</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab2_1_1_1_1 hd_b_niceng156er19.appb.tab2_1_1_28_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">24 quality of well-being.tw.</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab2_1_1_1_1 hd_b_niceng156er19.appb.tab2_1_1_28_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">25 qwb.tw.</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab2_1_1_1_1 hd_b_niceng156er19.appb.tab2_1_1_28_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">26 willingness to pay.tw.</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab2_1_1_1_1 hd_b_niceng156er19.appb.tab2_1_1_28_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">27 standard gamble*.tw.</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab2_1_1_1_1 hd_b_niceng156er19.appb.tab2_1_1_28_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">28 time trade off.tw.</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab2_1_1_1_1 hd_b_niceng156er19.appb.tab2_1_1_28_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">29 time tradeoff.tw.</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab2_1_1_1_1 hd_b_niceng156er19.appb.tab2_1_1_28_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">30 tto.tw.</td></tr><tr><td headers="hd_h_niceng156er19.appb.tab2_1_1_1_1 hd_b_niceng156er19.appb.tab2_1_1_28_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">31 or/1-30</td></tr></tbody></table></div></div></article><article data-type="fig" id="figobniceng156er19appcfig1"><div id="niceng156er19.appc.fig1" class="figure"><div class="graphic"><a href="/core/lw/2.0/html/tileshop_pmc/tileshop_pmc_inline.html?title=Image%20niceng156er19appcf1&p=BOOKS&id=556906_niceng156er19appcf1.jpg" target="tileshopwindow" class="inline_block pmc_inline_block ts_canvas img_link" title="Click on image to zoom"><div class="ts_bar small" title="Click on image to zoom"></div><img data-src="/books/NBK556906/bin/niceng156er19appcf1.jpg" alt="Image niceng156er19appcf1" class="tileshop" title="Click on image to zoom" /></a></div></div></article><article data-type="fig" id="figobniceng156er19appdfig1"><div id="niceng156er19.appd.fig1" class="figure"><div class="graphic"><a href="/core/lw/2.0/html/tileshop_pmc/tileshop_pmc_inline.html?title=Image%20niceng156er19appdf1&p=BOOKS&id=556906_niceng156er19appdf1.jpg" target="tileshopwindow" class="inline_block pmc_inline_block ts_canvas img_link" title="Click on image to zoom"><div class="ts_bar small" title="Click on image to zoom"></div><img data-src="/books/NBK556906/bin/niceng156er19appdf1.jpg" alt="Image niceng156er19appdf1" class="tileshop" title="Click on image to zoom" /></a></div></div></article><article data-type="table-wrap" id="figobniceng156er19appftab1"><div id="niceng156er19.appf.tab1" class="table"><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK556906/table/niceng156er19.appf.tab1/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng156er19.appf.tab1_lrgtbl__"><table><thead><tr><th id="hd_h_niceng156er19.appf.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Research recommendation</th><th id="hd_h_niceng156er19.appf.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Does tranexamic acid improve survival in people who are having repair (EVAR or open surgical repair) of a ruptured AAA?</th></tr></thead><tbody><tr><td headers="hd_h_niceng156er19.appf.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Population</td><td headers="hd_h_niceng156er19.appf.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">People with a confirmed ruptured abdominal aortic aneurysm who are expected to undergo emergency aneurysm repair</td></tr><tr><td headers="hd_h_niceng156er19.appf.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Intervention(s)</td><td headers="hd_h_niceng156er19.appf.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Tranexamic acid (administered during transfer or upon arrival at a regional vascular service)</td></tr><tr><td headers="hd_h_niceng156er19.appf.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Comparator(s)</td><td headers="hd_h_niceng156er19.appf.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Placebo, or no intervention</td></tr><tr><td headers="hd_h_niceng156er19.appf.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Outcomes</td><td headers="hd_h_niceng156er19.appf.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<ul><li class="half_rhythm"><div>Perioperative morbidity and mortality</div></li><li class="half_rhythm"><div>Bleeding/need for transfusion</div></li><li class="half_rhythm"><div>Myocardial infarction</div></li><li class="half_rhythm"><div>Renal failure</div></li><li class="half_rhythm"><div>Adverse effects of intervention – stroke, acute limb ischaemia, venous thromboembolism</div></li><li class="half_rhythm"><div>Quality of life</div></li><li class="half_rhythm"><div>Resource use, including of intensive care unit stay, and cost</div></li></ul></td></tr><tr><td headers="hd_h_niceng156er19.appf.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Study design</td><td headers="hd_h_niceng156er19.appf.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Randomised controlled trial</td></tr></tbody></table></div></div></article><article data-type="table-wrap" id="figobniceng156er19appftab2"><div id="niceng156er19.appf.tab2" class="table"><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK556906/table/niceng156er19.appf.tab2/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng156er19.appf.tab2_lrgtbl__"><table><thead><tr><th id="hd_h_niceng156er19.appf.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Potential criterion</th><th id="hd_h_niceng156er19.appf.tab2_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Explanation</th></tr></thead><tbody><tr><td headers="hd_h_niceng156er19.appf.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Importance to patients, service users or the population</td><td headers="hd_h_niceng156er19.appf.tab2_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Tranexamic acid is used to reduce blood loss in major trauma, postpartum bleeding and surgery. As a result, it could benefit people with a ruptured AAA. By slowing down blood loss from a ruptured aneurysm, the use of tranexamic acid could give emergency services more time to transfer a patient to regional vascular services, and regional vascular services more time to repair the ruptured aneurysm.</td></tr><tr><td headers="hd_h_niceng156er19.appf.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Relevance to NICE guidance</td><td headers="hd_h_niceng156er19.appf.tab2_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Medium priority: no recommendations were made in this guideline due to a lack of evidence, and further research would allow for recommendations to be possible in future guideline updates.</td></tr><tr><td headers="hd_h_niceng156er19.appf.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Current evidence base</td><td headers="hd_h_niceng156er19.appf.tab2_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">No evidence was found that assessed the efficacy of tranexamic acid for increasing survival of people with ruptured AAA.</td></tr><tr><td headers="hd_h_niceng156er19.appf.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Equality</td><td headers="hd_h_niceng156er19.appf.tab2_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">No specific equality concerns are relevant to this research recommendation.</td></tr><tr><td headers="hd_h_niceng156er19.appf.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Feasibility</td><td headers="hd_h_niceng156er19.appf.tab2_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">There is a sufficiently large and well defined population available that multicentre randomised controlled trials in this area should be feasible.</td></tr></tbody></table></div></div></article></div><div id="jr-scripts"><script src="/corehtml/pmc/jatsreader/ptpmc_3.22/js/libs.min.js"> </script><script src="/corehtml/pmc/jatsreader/ptpmc_3.22/js/jr.min.js"> </script></div></div>
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