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Badulescu OV, Bararu Bojan I, Badescu MC, Filip N, Chelsău A, Ciocoiu M, Vladeanu M, Filip A, Forna N, Sirbu MT, Ungureanu C, Sîrbu PD. Thromboembolic Disease in Haemophilic Patients Undergoing Major Orthopaedic Surgery: Is Thromboprophylaxis Mandatory? Diagnostics (Basel) 2022; 13:diagnostics13010013. [PMID: 36611305 PMCID: PMC9818461 DOI: 10.3390/diagnostics13010013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 12/05/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022] Open
Abstract
Haemophilia is a rare genetic disorder, that results from various degrees of deficiency of coagulation factor VIII (haemophilia A), or factor IX (haemophilia B), with an X-linked transmission. The patients affected are in the majority of cases males (who inherit the affected X-chromosome from the maternal side), with rare cases of females with haemophilia (FVIII or FIX < 40 IU/dL), situations in which both X-chromosomes are affected, or one is affected, and the other one is inactive (known as carrier). The hypocoagulable state due to the deficiency of clotting factors, manifests as an excessive, recurrent tendency to bleeding, which positively correlates with plasmatic levels. Severe haemophilia results in hemarthrosis, although recent data have shown that moderate or even mild disease can lead to joint bleeding. Recurrent episodes of haemorrhages, usually affecting large joints such as knees, elbows, or ankles, lead to joint remodelling and subsequent haemophilic arthropathy, which may require arthroplasty as a last therapeutic option. Orthopaedic patients have the highest risk among all for deep vein thrombosis (DVT) and venous thromboembolism (VTE) with morbid and potentially fatal consequences. While for the rest of the population thromboprophylaxis in orthopaedic surgery is efficient, relatively safe, and widely used, for patients with haemophilia who are considered to have a low thromboembolic risk, there is great controversy. The great heterogeneity of this particular population, and the lack of clinical trials, with only case reports or observational studies, makes thromboprophylaxis in major orthopaedic surgery a tool to be used by every clinician based on experience and case particularities. This review aims to briefly summarise the latest clinical data and to offer an insight into the current recommendations that readers would find useful in daily practice.
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Affiliation(s)
- Oana Viola Badulescu
- Department of Pathophysiology, Morpho-Functional Sciences (II), Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Iris Bararu Bojan
- Department of Pathophysiology, Morpho-Functional Sciences (II), Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Minerva Codruta Badescu
- Department of Internal Medicine, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- Correspondence: (M.C.B.); (N.F.); (A.C.)
| | - Nina Filip
- Department of Biochemistry, Morpho-Functional Sciences (II), Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- Correspondence: (M.C.B.); (N.F.); (A.C.)
| | - Alina Chelsău
- Institute of Cardiovascular Diseases, G.I.M. Georgescu, 700503 Iasi, Romania
- Correspondence: (M.C.B.); (N.F.); (A.C.)
| | - Manuela Ciocoiu
- Department of Pathophysiology, Morpho-Functional Sciences (II), Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Maria Vladeanu
- Department of Pathophysiology, Morpho-Functional Sciences (II), Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Alexandru Filip
- Department of Orthopedics and Traumatology, Surgical Science (II), Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Norin Forna
- Department of Orthopedics and Traumatology, Surgical Science (II), Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Mihnea Theodor Sirbu
- Department of Orthopedics and Traumatology, Surgical Science (II), Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Carmen Ungureanu
- Department Morpho-Functional Sciences (I), Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Paul-Dan Sîrbu
- Department of Orthopedics and Traumatology, Surgical Science (II), Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
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Franchini M, Mannucci PM. The hemostatic balance revisited through the lessons of mankind evolution. Intern Emerg Med 2008; 3:3-8. [PMID: 18283529 DOI: 10.1007/s11739-008-0100-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2007] [Accepted: 07/06/2007] [Indexed: 11/24/2022]
Abstract
Under physiologic conditions, a hemostatic balance is achieved through the effects of natural procoagulant and anticoagulant factors which, in equilibrium with each other, provide hemostasis at the sites of vascular injury. Abnormalities of these hemostasis factors can result in a tendency toward hemorrhagic or thrombotic events. In this review the influence of inherited prothrombotic risk factors--especially the more frequent factor V Leiden and prothrombin gene mutations--on normal and abnormal hemostasis is analyzed from an evolutionary point of view. The effect of inherited bleeding disorders on the development of thrombotic or atherosclerotic processes is also discussed.
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Affiliation(s)
- Massimo Franchini
- Transfusion and Hemophilia Center, City Hospital of Verona, Piazzale Ludovico Scuro, 37134 Verona, Italy.
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Bos MHA, Meijerman DWE, van der Zwaan C, Mertens K. Does activated protein C-resistant factor V contribute to thrombin generation in hemophilic plasma? J Thromb Haemost 2005; 3:522-30. [PMID: 15748243 DOI: 10.1111/j.1538-7836.2005.01181.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
In this study we assessed the role of factor V (FV) inactivation in hemophilic plasma with particular reference to the activated protein C (APC)-resistant variants FV-R506Q (FV Leiden) and FV-R306T (FV Cambridge). Purified recombinant full-length FV carrying these single substitutions and FV-R306T/R506Q were used in thrombin generation experiments. Plasma was first immunodepleted of FV, and subsequently of factors VIII, IX, or combinations thereof. Thrombin generation was initiated by low concentrations of recombinant tissue factor. Recombinant soluble thrombomodulin (TM) was used to trigger the APC system. Surprisingly, TM concentrations that reduced thrombin generation in normal plasma by no more than 50% virtually abolished thrombin formation in plasma deficient in the factor VIII/IX complex. This was already apparent at TM levels as low as 0.1 nmol L(-1). By varying the concentrations of purified (activated) protein C to plasma that was additionally depleted of protein C, we confirmed that impaired thrombin generation indeed was the result of the action of APC. In contrast, this did not occur when FV-depleted plasma had been reconstituted with FV-R306T/R506Q. Addition of FV-R306T or FV-R506Q partially reduced prothrombin activation, demonstrating the involvement of both APC cleavage sites. FV inactivation also occurred on the surface of human microvascular endothelial cells. Apparently, these cells express sufficient TM to down-regulate thrombin production via the APC pathway. We further conclude that in hemophilic plasma this pathway can induce a secondary defect because of premature FV inactivation. It therefore seems conceivable that APC-resistant FV has the potential of alleviating hemophilic bleeding.
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Affiliation(s)
- M H A Bos
- The Department of Plasma Proteins, Sanquin Research at CLB, Amsterdam, the Netherlands
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