1
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Ali AE, Becker RC. The foundation for investigating factor XI as a target for inhibition in human cardiovascular disease. J Thromb Thrombolysis 2024:10.1007/s11239-024-02985-0. [PMID: 38662114 DOI: 10.1007/s11239-024-02985-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/13/2024] [Indexed: 04/26/2024]
Abstract
Anticoagulant therapy is a mainstay in the management of patients with cardiovascular disease and related conditions characterized by a heightened risk for thrombosis. Acute coronary syndrome, chronic coronary syndrome, ischemic stroke, and atrial fibrillation are the most common. In addition to their proclivity for thrombosis, each of these four conditions is also characterized by local and systemic inflammation, endothelial/endocardial injury and dysfunction, oxidative stress, impaired tissue-level reparative capabilities, and immune dysregulation that plays a critical role in linking molecular events, environmental triggers, and phenotypic expressions. Knowing that cardiovascular disease and thrombosis are complex and dynamic, can the scientific community identify a common pathway or specific point of interface susceptible to pharmacological inhibition or alteration that is likely to be safe and effective? The contact factors of coagulation may represent the proverbial "sweet spot" and are worthy of investigation. The following review provides a summary of the fundamental biochemistry of factor XI, its biological activity in thrombosis, inflammation, and angiogenesis, new targeting drugs, and a pragmatic approach to managing hemostatic requirements in clinical trials and possibly day-to-day patient care in the future.
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Affiliation(s)
- Ahmed E Ali
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Richard C Becker
- Department of Internal Medicine, College of Medicine, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH, 45267, USA.
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Li X, Chen M, Wang Y, Zhou X, Wang M, Zou L. Successful use of peritoneal dialysis after abdominal surgery in a patient with factor XI deficiency: A case report. Semin Dial 2023; 36:178-182. [PMID: 36597266 DOI: 10.1111/sdi.13136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 12/19/2022] [Indexed: 01/05/2023]
Abstract
Factor XI (FXI) deficiency is a rare bleeding disorder of unpredictable severity that correlates poorly with FXI coagulation activity and that poses great challenges for perioperative hemostatic management and the dialysis methods potentially available to new end-stage renal disease (ESRD) patients. We describe an individual with both ESRD and severe FXI deficiency, who successfully underwent peritoneal dialysis (PD) after emergency abdominal surgery. In the traditional concept, recent abdominal surgery is a contraindication to PD, especially for patients with bleeding risk. However, this case report highlights that PD can still be an possible option for patients with FXI deficiency who have just undergone abdominal surgery; laparoscopic PD catheter placement offers a chance to establish PD access in patients traditionally viewed as noncandidates for this method. Careful perioperative management and fresh frozen plasma transfusion ensure successful surgery. This case should be of help to clinicians and patients considering PD in similar situations.
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Affiliation(s)
- Xueying Li
- School of Clinical Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, China.,Department of Nephrology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Ming Chen
- Department of Nephrology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Yong Wang
- The 2nd Department of Foot and Ankle, Sichuan Provincial Orthopedics Hospital, Chengdu, China
| | - Xuelei Zhou
- Department of Gastroenterology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Min Wang
- Department of Surgery, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Lihua Zou
- Department of Nephrology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
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3
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Martinuzzo M, Seehaus CM, López MS, Barrera LH, Garrott LF, Maffassanti PQ, Privitera V, Chuliber F, Penchasky D, Viñuales ES, Arbelbide J. Acquired FXI deficiency in a systemic lupus erythematosus patient: Evolution and coagulation phenotypic changed to lupus anticoagulant during immunosuppressive therapy. Int J Lab Hematol 2022; 44:e269-e274. [PMID: 35883223 DOI: 10.1111/ijlh.13937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 07/04/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Marta Martinuzzo
- Central Laboratory, Biochemistry, Instituto Universitario del Hospital Italiano de Buenos Aires, Buenos Aires, CABA, Argentina
| | | | - Marina Sol López
- Central Laboratory, Biochemistry, Instituto Universitario del Hospital Italiano de Buenos Aires, Buenos Aires, CABA, Argentina
| | - Luis Horacio Barrera
- Central Laboratory, Biochemistry, Instituto Universitario del Hospital Italiano de Buenos Aires, Buenos Aires, CABA, Argentina
| | | | - Paulina Quiñones Maffassanti
- Central Laboratory, Instituto Universitario del Hospital Italiano de Buenos Aires, Buenos Aires, CABA, Argentina
| | - Verónica Privitera
- Hematology, Hospital Italiano de Buenos Aires, Buenos Aires, CABA, Argentina
| | - Fernando Chuliber
- Hematology, Hospital Italiano de Buenos Aires, Buenos Aires, CABA, Argentina
| | - Diana Penchasky
- Hematology, Hospital Italiano de Buenos Aires, Buenos Aires, CABA, Argentina
| | - Estela S Viñuales
- Hematology, Hospital Italiano de Buenos Aires, Buenos Aires, CABA, Argentina
| | - Jorge Arbelbide
- Hematology, Hospital Italiano de Buenos Aires, Buenos Aires, CABA, Argentina
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Guo WJ, Chen WY, Yu XR, Shen L, Huang YG. Intraoperative thromboelastography-guided transfusion in a patient with factor XI deficiency: A case report. World J Clin Cases 2022; 10:242-248. [PMID: 35071523 PMCID: PMC8727276 DOI: 10.12998/wjcc.v10.i1.242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 07/12/2021] [Accepted: 11/25/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Factor XI (FXI) deficiency, also known as hemophilia C, is a rare bleeding disorder of unpredictable severity that correlates poorly with FXI coagulation activity. This often poses great challenges in perioperative hemostatic management. Thromboelastography (TEG) is a method for testing blood coagulation using a viscoelastic hemostatic assay of whole blood to assess the overall coagulation status. Here, we present the successful application of intraoperative TEG monitoring in an FXI-deficient patient as an individualized blood transfusion strategy.
CASE SUMMARY A 21-year-old male patient with FXI deficiency was scheduled to undergo reconstructive surgery for macrodactyly of the left foot under general anesthesia. To minimize his bleeding risk, he was scheduled to receive fresh frozen plasma (FFP) as an empirical prophylactic FXI replacement at a dose of 15-20 mL/kg body weight (900-1200 mL) before surgery. Subsequent FFP transfusion was to be adjusted according to surgical need. Instead, TEG assessment was used at the beginning and toward the end of his surgery. According to intraoperative TEG results, the normalization of coagulation function was achieved with an infusion of only 800 mL FFP, and blood loss was minimal. The patient showed an uneventful postoperative course and was discharged on postoperative day 8.
CONCLUSION TEG can be readily applied in the intraoperative period to individualize transfusion needs in patients with rare inherited coagulopathy.
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Affiliation(s)
- Wen-Juan Guo
- Department of Anesthesiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Wei-Yun Chen
- Department of Anesthesiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Xue-Rong Yu
- Department of Anesthesiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Le Shen
- Department of Anesthesiology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Yu-Guang Huang
- Department of Anesthesiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
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Abou-Ismail MY, Connell NT. How to manage bleeding disorders in aging patients needing surgery. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2021; 2021:529-535. [PMID: 34889441 PMCID: PMC8791143 DOI: 10.1182/hematology.2021000288] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
With improvements in medical care, the life expectancy of patients with bleeding disorders is approaching that of the general population. A growing population of older adult patients with bleeding disorders is at risk of age-related comorbidities and in need of various elective and emergent age-related procedures. The increased risk of thrombosis and volume overload in older adults complicates perioperative hemostatic management. Furthermore, antithrombotic treatment such as antiplatelet or anticoagulant therapy, which is frequently required for various cardiovascular interventions, requires a meticulous individualized approach. Evidence-based guidelines for the management of aging patients with bleeding disorders are lacking, largely due to the underrepresentation of older adult patients in clinical trials as well as the rarity of many such bleeding disorders. We discuss the current guidelines and recommendations in the perioperative hemostatic management of older adult patients with hemophilia and von Willebrand disease as well as other rare bleeding disorders. The optimal management of these patients is often complex and requires a thorough multidisciplinary and individualized approach involving hematologists, surgeons, anesthesiologists, and the specialists treating the underlying disorder.
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Affiliation(s)
- Mouhamed Yazan Abou-Ismail
- Division of Hematology and Hematologic Malignancies, Department of Internal Medicine, University of Utah, Salt Lake City, UT
| | - Nathan T Connell
- Hematology Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
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Burgos Pratx LD, Santoro DM, Mileo FG, Martinuzzo ME, Ardiles V, de Santibañes E, Salamone HJ. Management of factor XI deficiency in oncological liver and colorectal surgery by therapeutic plasma exchange: A case report. Transfus Apher Sci 2021; 60:103176. [PMID: 34127376 DOI: 10.1016/j.transci.2021.103176] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 05/28/2021] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Factor XI (FXI) deficiency is a rare congenital hemostatic disorder associated with increased bleeding tendency in trauma, surgery or when other hemostatic defects are present. Perioperative hemostatic management of a patient with a severe FXI deficiency undergoing major oncological liver and colorectal surgery with therapeutic plasma exchange (TPE) with fresh frozen plasma (FFP) is reported. CASE DESCRIPTION A 54-year-old male with severe FXI deficiency was scheduled for resection of synchronous rectal cancer and multiple liver metastases. Baseline prothrombin time (PT) was 97 %, activated partial thromboplastin time (aPTT) 89 s(s) and FXI levels <1 IU/dL. The rotational thromboelastometry (ROTEM™) presented a prolonged INTEM clotting time (CT) = 443 s (RV 100-240 s) and a clot formation time (CFT) = 110 s (RV 30-100 s). TPE with FFP was carried out achieving FXI levels up to 46 IU/dL and an aPTT of 33 s, normalizing thromboelastometry parameters to an INTEM CT = 152 s and a CFT = 86 s before the procedure. After surgery, the patient received daily FFP to maintain FXI levels above 30 IU/dL until discharge on the eighth day. A total of 30 FFP units were transfused during hospital stay. No significant bleeding events neither transfusion related complications were observed during the perioperative period. CONCLUSION Given the lack of correlation between FXI levels and bleeding risk, a multidisciplinary approach based on daily FXI levels monitoring, close clinical assessment and factor supplementation is mandatory. In conclusion, TPE with FFP is an efficacious alternative strategy to correct severe FXI deficiency in patients undergoing major surgery.
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Affiliation(s)
- L D Burgos Pratx
- Transfusion Medicine Deparment, Hospital Italiano de Buenos Aires, Argentina.
| | - D M Santoro
- Transfusion Medicine Deparment, Hospital Italiano de Buenos Aires, Argentina
| | - F G Mileo
- Department of Anesthesiology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - M E Martinuzzo
- Laboratorio Central del Hospital Italiano de Buenos Aires, Departamento de Bioquímica Aplicada, Instituto Universitario del Hospital Italiano, Buenos Aires, Argentina
| | - V Ardiles
- Department of Surgery, Division of HPB Surgery, Liver Transplant Unit, Hospital Italiano de Buenos Aires, Argentina
| | - E de Santibañes
- Department of Surgery, Division of HPB Surgery, Liver Transplant Unit, Hospital Italiano de Buenos Aires, Argentina
| | - H J Salamone
- Transfusion Medicine Deparment, Hospital Italiano de Buenos Aires, Argentina
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Fitzsimons MG, Leaf RK, Mack J, Bendapudi PK, Shen T, Cameron DE. Perioperative management of a redo aortic root replacement in a patient with severe factor XI deficiency. J Card Surg 2018; 33:86-89. [PMID: 29399875 DOI: 10.1111/jocs.13526] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Factor XI deficiency is associated with significant bleeding in the setting of trauma and surgery. We present a patient with FXI deficiency and multiple red blood cell allo-antibodies requiring repeat aortic root replacement and discuss the perioperative management of patients with FXI deficiency undergoing cardiac surgery.
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Affiliation(s)
- Michael G Fitzsimons
- Division of Cardiac Anesthesia, Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Rebecca Karp Leaf
- Division of Hematology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Johnathan Mack
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts
| | - Pavan K Bendapudi
- Division of Hematology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Tao Shen
- Division of Cardiac Anesthesia, Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Duke E Cameron
- Cardiac Surgery Division, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
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