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Chornenki NLJ, Shanjer M, James PD. Vascular abnormalities in patients with von Willebrand disease: A scoping review. J Thromb Haemost 2021; 19:2151-2160. [PMID: 34060212 DOI: 10.1111/jth.15410] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 05/07/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND Qualitative or quantitative defects of von Willebrand factor (VWF) such as in von Willebrand disease (VWD) are associated with vascular abnormalities, especially in the gastrointestinal (GI) tract. However, the locations, extent, and natural history of vascular abnormalities in patients with VWD is not well understood. To summarize the existing literature on the topic, we conducted a scoping review of vascular abnormalities in patients with VWD. METHODS We searched MEDLINE and EMBASE from inception to September 1, 2020, for studies clinically describing vascular abnormalities in VWD patients. Screening and data extraction was completed independently and in duplicate and each abnormality was documented individually. RESULTS After screening, 54 studies that reported patient level data comprising 146 patients were included. Type 2A (39%) and type 3 (14.4%) were the most common VWD subtypes. The most common site of vascular malformation was the GI tract, occurring in 124 patients (84.9%), whereas 18 (12.3%) had non-GI vascular abnormalities and 4 (2.7%) had both GI and non-GI vascular abnormalities. With respect to outcomes, the clinical course was not specified in the majority (55.5%) of patients. Survey and population level data were reported in nine studies, demonstrating vascular abnormalities occurred at higher rates in VWD and that VWD patients are overrepresented among those with those abnormalities. CONCLUSION Vascular malformations in patients with VWD occur primarily in the gastrointestinal tract. Type 2A and type 3 VWD are the most common subtypes affected. The clinical treatment and natural history of these abnormalities remains understudied and further research is needed.
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Affiliation(s)
| | - Maaz Shanjer
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Paula D James
- Department of Medicine, Queen's University, Kingston, ON, Canada
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2
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How I treat gastrointestinal bleeding in congenital and acquired von Willebrand disease. Blood 2021; 136:1125-1133. [PMID: 32584960 DOI: 10.1182/blood.2019003702] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 05/01/2020] [Indexed: 12/15/2022] Open
Abstract
Gastrointestinal (GI) bleeding is distinctive of severe von Willebrand disease (VWD), generally arising in older patients; in most cases, blood transfusion and hospitalization are required. The presence of arteriovenous malformations is often described when endoscopic examinations are performed. Patients with congenital type 3, 2A, and 2B are those most frequently affected by this symptom, possibly due to the loss of high-molecular-weight multimers of von Willebrand factor (VWF). GI bleeding can also occur in patients affected by acquired von Willebrand syndrome. Endoscopic examination of the GI tract is necessary to exclude ulcers and polyps or cancer as possible causes of GI bleeding. In congenital VWD, prophylaxis with VWF/factor VIII concentrates is generally started after GI-bleeding events, but this therapy is not always successful. Iron supplementation must be prescribed to avoid chronic iron deficiency. Possible rescue therapies (high-dose statins, octreotide, thalidomide, lenalidomide, and tamoxifen) were described in a few case reports and series; however, surgery may be necessary in emergency situations or if medical treatment fails to stop bleeding. In this article, we present several clinical cases that highlight the clinical challenges of these patients and possible strategies for their long-term management.
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3
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Paciullo F, Fierro T, Calcinaro F, Zucca Giucca G, Gresele P, Bury L. Long-term treatment with thalidomide for severe recurrent hemorrhage from intestinal angiodysplasia in Glanzmann Thrombasthenia. Platelets 2020; 32:288-291. [PMID: 32200672 DOI: 10.1080/09537104.2020.1745169] [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] [Indexed: 10/24/2022]
Abstract
Gastrointestinal angiodysplasia (GIA) is the most common cause of occult gastrointestinal bleeding (GIB) requiring often hospitalization and transfusions, especially in patients with hemorrhagic disorders. Thalidomide, impairing neo-angiogenesis, has been successfully used in the management of bleeding in patients with GIA and in particular in patients with inherited bleeding disorders. Only one case of short-term treatment with thalidomide in a patient with Glanzmann thrombasthenia (GT) and recurrent GIB due to GIA has been reported so far.We report the case of a woman with GT developing high frequency recurrent GIB due to GIA requiring repeated blood and platelet transfusions, who was treated with thalidomide obtaining a striking and stable reduction of GIB and of the requirement of platelet and blood transfusions for over 5 years. Moreover, we raise the suspicion that the association between GT and GIA may not be fortuitous.
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Affiliation(s)
- Francesco Paciullo
- Department of Medicine, Section of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Tiziana Fierro
- Department of Medicine, Section of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Filippo Calcinaro
- Division of Internal Medicine and Division of Immunology and Transfusion, Mazzoni Hospital, Ascoli Piceno, Italy
| | - Gianfranco Zucca Giucca
- Division of Internal Medicine and Division of Immunology and Transfusion, Mazzoni Hospital, Ascoli Piceno, Italy
| | - Paolo Gresele
- Department of Medicine, Section of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Loredana Bury
- Department of Medicine, Section of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy
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4
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Mirna M, Lichtenauer M, Theurl T, Ausserwinkler M, Topf A, Westphal T, Gampenrieder SP, Pretsch I, Greil R, Hoppe UC. Transcatheter aortic valve implantation in a patient with suspected hereditary von Willebrand disease and severe gastrointestinal bleeding - a case report. Scott Med J 2019; 64:142-147. [PMID: 31324129 DOI: 10.1177/0036933019862155] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION von Willebrand disease is the most common hereditary coagulopathy and is characterised by a deficiency in the quantity or quality of the von Willebrand factor. Heyde Syndrome, in contrast, is an acquired form of von Willebrand syndrome (AVWS) due to calcific aortic valve stenosis, characterised by gastrointestinal bleeding from angiodysplasia. CASE PRESENTATION A 73-year-old patient presented with severe gastrointestinal bleeding and stated that she suffered from hereditary von Willebrand disease. Upon echocardiography, a severe aortic valve stenosis was found, and hence the suspicion of additional AVWS was raised. Since endoscopic interventions and conservative therapeutic approaches did not result in a cessation of the bleeding, transcatheter aortic valve implantation (TAVI) was performed to stop the additional shear stress on von Willebrand factor. This resulted in cessation of the bleeding. CONCLUSION Retrospectively, this life-threatening gastrointestinal bleeding was a result of severe Heyde Syndrome, which could be alleviated by TAVI. Whether the patient had suffered from inherited von Willebrand disease in the past, remains uncertain. AVWS should be considered in patients with suspected inherited von Willebrand disease and concomitant severe aortic valve stenosis, since it constitutes a treatable cause of a potentially severe bleeding disorder.
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Affiliation(s)
- Moritz Mirna
- Specialty Trainee, Department of Internal Medicine II, Department of Cardiology, Paracelsus Medical University of Salzburg, Austria
| | - Michael Lichtenauer
- Associate Professor of Medicine, Department of Internal Medicine II, Department of Cardiology, Paracelsus Medical University of Salzburg, Austria
| | - Thomas Theurl
- Specialty Trainee, Department of Internal Medicine II, Department of Cardiology, Paracelsus Medical University of Salzburg, Austria
| | - Mathias Ausserwinkler
- Specialty Trainee, Department of Internal Medicine II, Department of Cardiology, Paracelsus Medical University of Salzburg, Austria
| | - Albert Topf
- Specialty Trainee, Department of Internal Medicine II, Department of Cardiology, Paracelsus Medical University of Salzburg, Austria
| | - Theresa Westphal
- Specialty Trainee, Department of Internal Medicine III with Haematology, Medical Oncology, Haemostaseology, Infectiology and Rheumatology, Oncologic Center, Paracelsus Medical University of Salzburg, Austria
| | - Simon Peter Gampenrieder
- Senior Physician, Department of Internal Medicine III with Haematology, Medical Oncology, Haemostaseology, Infectiology and Rheumatology, Oncologic Center, Paracelsus Medical University of Salzburg, Austria
| | - Ingrid Pretsch
- Senior Physician, Department of Internal Medicine II, Department of Cardiology, Paracelsus Medical University of Salzburg, Austria
| | - Richard Greil
- Head of Department and Professor of Medicine, Department of Internal Medicine III with Haematology, Medical Oncology, Haemostaseology, Infectiology and Rheumatology, Oncologic Center, Paracelsus Medical University of Salzburg, Austria
| | - Uta C Hoppe
- Head of Department and Professor of Medicine, Department of Internal Medicine II, Department of Cardiology, Paracelsus Medical University of Salzburg, Austria
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5
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Randi AM, Smith KE, Castaman G. von Willebrand factor regulation of blood vessel formation. Blood 2018; 132:132-140. [PMID: 29866817 PMCID: PMC6182264 DOI: 10.1182/blood-2018-01-769018] [Citation(s) in RCA: 119] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Accepted: 04/18/2018] [Indexed: 02/06/2023] Open
Abstract
Several important physiological processes, from permeability to inflammation to hemostasis, take place at the vessel wall and are regulated by endothelial cells (ECs). Thus, proteins that have been identified as regulators of one process are increasingly found to be involved in other vascular functions. Such is the case for von Willebrand factor (VWF), a large glycoprotein best known for its critical role in hemostasis. In vitro and in vivo studies have shown that lack of VWF causes enhanced vascularization, both constitutively and following ischemia. This evidence is supported by studies on blood outgrowth EC (BOEC) from patients with lack of VWF synthesis (type 3 von Willebrand disease [VWD]). The molecular pathways are likely to involve VWF binding partners, such as integrin αvβ3, and components of Weibel-Palade bodies, such as angiopoietin-2 and galectin-3, whose storage is regulated by VWF; these converge on the master regulator of angiogenesis and endothelial homeostasis, vascular endothelial growth factor signaling. Recent studies suggest that the roles of VWF may be tissue specific. The ability of VWF to regulate angiogenesis has clinical implications for a subset of VWD patients with severe, intractable gastrointestinal bleeding resulting from vascular malformations. In this article, we review the evidence showing that VWF is involved in blood vessel formation, discuss the role of VWF high-molecular-weight multimers in regulating angiogenesis, and review the value of studies on BOEC in developing a precision medicine approach to validate novel treatments for angiodysplasia in congenital VWD and acquired von Willebrand syndrome.
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Affiliation(s)
- Anna M Randi
- Vascular Sciences, Imperial Centre for Translational and Experimental Medicine, National Heart and Lung Institute, Imperial College London, London, United Kingdom; and
| | - Koval E Smith
- Vascular Sciences, Imperial Centre for Translational and Experimental Medicine, National Heart and Lung Institute, Imperial College London, London, United Kingdom; and
| | - Giancarlo Castaman
- Center for Bleeding Disorders and Coagulation, Department of Oncology, Careggi University Hospital, Florence, Italy
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6
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McFarlane M, O’Flynn L, Ventre R, Disney BR. Emerging role of thalidomide in the treatment of gastrointestinal bleeding. Frontline Gastroenterol 2018; 9:98-104. [PMID: 29588836 PMCID: PMC5868454 DOI: 10.1136/flgastro-2017-100870] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 09/22/2017] [Accepted: 10/18/2017] [Indexed: 02/04/2023] Open
Abstract
Thalidomide was initially synthesised in 1954 and marketed as a sedative and antiemetic for morning sickness. It was withdrawn in 1961 due to the realisation that it was teratogenic with over 10 000 children born with congenital abnormalities. Since then it has been used for treatment of dermatological and oncological conditions, including myeloma. In 1994, it was found to have a potent antiangiogenic effect via downregulation of vascular endothelial growth factor (VEGF). This has led to its use in gastrointestinal bleeding, as vascular abnormalities such as angiodysplasia have been found to have elevated VEGF levels. This article will review the current evidence of the use of thalidomide in bleeding associated with gastrointestinal vascular malformations, including angiodysplasia, gastric cancer and radiation-induced proctitis.
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Affiliation(s)
- Michael McFarlane
- Department of Gastroenterology, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Lauren O’Flynn
- Department of Gastroenterology, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Rachel Ventre
- Department of Gastroenterology, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Benjamin R Disney
- Department of Gastroenterology, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
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7
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Muslem R, Caliskan K, Leebeek FWG. Acquired coagulopathy in patients with left ventricular assist devices. J Thromb Haemost 2018; 16:429-440. [PMID: 29274191 DOI: 10.1111/jth.13933] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Indexed: 08/31/2023]
Abstract
Chronic heart failure (HF) is a major emerging healthcare problem, associated with a high morbidity and mortality. Left ventricular assist devices (LVADs) have emerged as a successful treatment option for patients with end-stage HF. Despite its great benefit, the use of LVAD is associated with a high risk of complications. Bleeding, pump thrombosis and thromboembolic events are frequently observed complications, with bleeding complications occurring in over a third of the patients. Although the design of the third-generation LVAD has improved greatly, these hemostatic complications still occur. The introduction of an LVAD into the circulatory system results in an altered hematological balance as a consequence of blood-pump interactions, changes in hemodynamics, the rheology, and the concomitant need for anticoagulation while implanted with an LVAD. The majority, if not all, LVAD patients experience a form of platelet dysfunction and impaired von Willebrand factor activity, leading to acquired coagulopathy disorders. Different diagnostic tools and treatment strategies have been reported; however, they require validation in LVAD patients. The present review focuses on acquired coagulopathies, describing the incidence, impact and underlying mechanism of acquired coagulopathy disorders in patients supported by LVADs. In addition, we will discuss diagnostic and management strategies for these acquired coagulopathies.
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Affiliation(s)
- R Muslem
- Department of Cardiothoracic Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - K Caliskan
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - F W G Leebeek
- Department of Hematology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
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8
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Franchini M, Mannucci PM. Gastrointestinal angiodysplasia and bleeding in von Willebrand disease. Thromb Haemost 2017; 112:427-31. [DOI: 10.1160/th13-11-0952] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2013] [Accepted: 04/08/2014] [Indexed: 12/24/2022]
Abstract
SummaryVon Willebrand disease (VWD), the most common genetic bleeding disorder, is characterised by a quantitative or qualitative defect of von Willebrand factor (VWF). Patients with VWD suffer from mucocutaneous bleeding, of severity usually proportional to the degree of VWF defect. In particular, gastrointestinal bleeding associated with angiodysplasia is often a severe symptom of difficult management. This review focuses on the pathophysiology, diagnosis and treatment of VWD-associated gastrointestinal angiodysplasia and related bleeding.
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9
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Becq A, Rahmi G, Perrod G, Cellier C. Hemorrhagic angiodysplasia of the digestive tract: pathogenesis, diagnosis, and management. Gastrointest Endosc 2017; 86:792-806. [PMID: 28554655 DOI: 10.1016/j.gie.2017.05.018] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 05/18/2017] [Indexed: 02/06/2023]
Affiliation(s)
- Aymeric Becq
- Gastroenterology and Endoscopy division, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, University Paris-Descartes Sorbonne-Paris Cité, Paris, France
| | - Gabriel Rahmi
- Gastroenterology and Endoscopy division, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, University Paris-Descartes Sorbonne-Paris Cité, Paris, France
| | - Guillaume Perrod
- Gastroenterology and Endoscopy division, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, University Paris-Descartes Sorbonne-Paris Cité, Paris, France
| | - Christophe Cellier
- Gastroenterology and Endoscopy division, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, University Paris-Descartes Sorbonne-Paris Cité, Paris, France
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10
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Duarte BKL, de Souza SM, Costa-Lima C, Medina SS, Ozelo MC. Thalidomide for the Treatment of Gastrointestinal Bleeding Due to Angiodysplasia in a Patient with Glanzmann's Thrombasthenia. Hematol Rep 2017; 9:6961. [PMID: 28670433 PMCID: PMC5477473 DOI: 10.4081/hr.2017.6961] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 03/21/2017] [Indexed: 01/06/2023] Open
Abstract
Angiodysplasia is a frequent cause of persistent gastrointestinal (GI) hemorrhage in elderly patients. Although GI bleeding isn't the most common manifestation in patients with bleeding disorders, when present, it represents a challenging complication. We describe a 62-year-old patient with Glanzmann's thrombasthenia, who used thalidomide for severe and recurrent GI bleeding. For 6 months, the patient experienced temporary control of GI bleeding with thalidomide in a daily oral dose of 100 mg. The anti-angiogenic effects of thalidomide have recently been explored by several groups, particularly in the management of bleeding from angiodysplasia, including cases with von Willebrand disease. Here, we review the relevant descriptions of the use of thalidomide in this situation, and also discuss potential reasons why we observed only a temporary control of the GI bleeding in our patient, such as the use of low-dose regimen due to limitations posed by thalidomide side effects.
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Affiliation(s)
- Bruno K L Duarte
- Instituto Nacional de Ciência e Tecnologia do Sangue, Hemocentro Unicamp, Campinas, SP, Brazil
| | - Sílvia M de Souza
- Instituto Nacional de Ciência e Tecnologia do Sangue, Hemocentro Unicamp, Campinas, SP, Brazil
| | - Carolina Costa-Lima
- Instituto Nacional de Ciência e Tecnologia do Sangue, Hemocentro Unicamp, Campinas, SP, Brazil
| | - Samuel S Medina
- Instituto Nacional de Ciência e Tecnologia do Sangue, Hemocentro Unicamp, Campinas, SP, Brazil
| | - Margareth C Ozelo
- Instituto Nacional de Ciência e Tecnologia do Sangue, Hemocentro Unicamp, Campinas, SP, Brazil.,Department of Internal Medicine, School of Medical Sciences, University of Campinas, Campinas, SP, Brazil
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11
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Recombinant von Willebrand factor for severe gastrointestinal bleeding unresponsive to other treatments in a patient with type 2A von Willebrand disease: a case report. Blood Coagul Fibrinolysis 2017; 28:570-575. [PMID: 28379876 PMCID: PMC5642339 DOI: 10.1097/mbc.0000000000000632] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A recombinant von Willebrand factor (rVWF) was recently approved in the United States for on-demand treatment and control of bleeding episodes in adults with von Willebrand disease (VWD). In contrast to plasma-derived VWF products available in the United States, rVWF does not contain factor VIII (FVIII). To date, there is no published experience of rVWF in clinical practice. We report the acute and prophylactic use of rVWF in a patient with VWD type 2A and severe gastrointestinal bleeding. Dosing with plasma-derived VWF/FVIII concentrates was constrained by FVIII accumulation; the bleeding was unresponsive, and multiple red blood cell transfusions were required. After initiation of rVWF (4200 IU every other day), bleeding symptoms subsided, and no red blood cell transfusions were required during more than 3 months of prophylactic therapy (most recent dosage: 2800 IU every other day). rVWF may be effective in the prevention, as well as treatment, of severe bleeding symptoms in VWD.
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12
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El-Gendy H, Shohdy KS, Maghraby GG, Abadeer K, Mahmoud M. Gastric antral vascular ectasia in systemic sclerosis: Where do we stand? Int J Rheum Dis 2017; 20:2133-2139. [PMID: 28217887 DOI: 10.1111/1756-185x.13047] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Gastric antral vascular ectasia (GAVE) continues to be a challenge in both diagnosis and treatment. GAVE has a diverse group of associations and presumed causes, including cirrhosis, chronic renal failure and autoimmune connective tissue diseases. However, in most occasions, the management plan of GAVE itself is the same whatever the underlying disease by using Argon plasma coagulation (APC). Herein, we will discuss three cases of systemic sclerosis-associated GAVE presenting with either acute or chronic gastrointestinal bleeding showing variable responses to APC. Anemia and telangiectasia may be the first striking presentation of systemic sclerosis (SSc). Renal artery stenosis, aortic stenosis, widespread cutaneous and mucosal telangiectasia and hypertension seem to be associated with poor prognosis and should prompt rapid intervention and careful follow-up. Moreover, the hunt for molecular underpinnings of the broad array of vascular lesions in SSc has to include von Willebrand factor and endoglin. Eventually, we will review the recent alternatives that can be effective in SSc-GAVE, such as band ligation, hematopoietic stem cells transplantation and immunotherapy.
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Affiliation(s)
- Hala El-Gendy
- Rheumatology & Clinical Immunology Unit, Internal Medicine Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Kyrillus S Shohdy
- Rheumatology & Clinical Immunology Unit, Internal Medicine Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Gehad G Maghraby
- Rheumatology & Clinical Immunology Unit, Internal Medicine Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | | | - Moustafa Mahmoud
- Rheumatology & Clinical Immunology Unit, Internal Medicine Department, Faculty of Medicine, Cairo University, Cairo, Egypt
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13
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Boey JP, Hahn U, Sagheer S, McRae SJ. Thalidomide in angiodysplasia-related bleeding. Intern Med J 2016; 45:972-6. [PMID: 26332623 DOI: 10.1111/imj.12850] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2014] [Accepted: 05/31/2015] [Indexed: 12/17/2022]
Abstract
Gastrointestinal haemorrhage from angiodysplastic lesions is not only difficult to identify, but often refractory to endoscopic intervention. Patients often require substantial transfusion support. Thalidomide has emerged as a promising medical strategy in angiodysplasia-related bleeding. We present our experience and report the findings from a review of the literature. Despite its side-effect profile, thalidomide remains the therapeutic modality with the best evidence in this difficult clinical scenario.
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Affiliation(s)
- J P Boey
- Department of Haematology, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - U Hahn
- Department of Haematology, Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - S Sagheer
- Department of Haematology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - S J McRae
- Department of Haematology, Queen Elizabeth Hospital, Adelaide, South Australia, Australia.,Department of Haematology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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14
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Engelen ET, van Galen KPM, Schutgens REG. Thalidomide for treatment of gastrointestinal bleedings due to angiodysplasia: a case report in acquired von Willebrand syndrome and review of the literature. Haemophilia 2015; 21:419-29. [PMID: 25929157 DOI: 10.1111/hae.12701] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2015] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Acquired von Willebrand syndrome is a rare bleeding disorder and treatment of the associated gastrointestinal (GI) bleeding due to angiodysplasia is challenging. AIM The aim of this study was to present a new case on the successful use of thalidomide in a patient with acquired von Willebrand syndrome and recurrent angiodysplasia-related GI bleedings, and to conduct a literature review on the use of thalidomide in patients with GI angiodysplasia. METHODS A literature review was conducted, searching the electronic databases PubMed, Embase and Cochrane. RESULTS We present a 75-year-old woman with IgG MGUS-associated acquired von Willebrand syndrome (AVWS) who suffered from recurrent gastrointestinal (GI) bleedings and epistaxis. Treatment with immunoglobulins, desmopressin, Haemate-P and blood transfusions failed to achieve long-term haemostasis. Eventually, after these bleedings relapsed for almost a decade at 1- to 3-month intervals, thalidomide was prescribed. Since then, only one single nose bleed and one single melaena episode had occurred. She currently remains in remission of GI bleeds after 3 years and 3 months follow-up. The literature review revealed a beneficial effect of thalidomide in reducing GI bleeding due to angiodysplasia, including four case reports on inherited von Willebrand disease. CONCLUSION In conclusion, thalidomide can be a reasonable option for the treatment of recurrent GI bleeding due to angiodysplasia in AVWS and we report for the first time that refractory or relapsing GI bleeding in patients with AVWS can successfully be controlled with thalidomide.
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Affiliation(s)
- E T Engelen
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht, The Netherlands
| | - K P M van Galen
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht, The Netherlands
| | - R E G Schutgens
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht, The Netherlands
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15
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Makris M, Federici AB, Mannucci PM, Bolton-Maggs PHB, Yee TT, Abshire T, Berntorp E. The natural history of occult or angiodysplastic gastrointestinal bleeding in von Willebrand disease. Haemophilia 2014; 21:338-342. [PMID: 25381842 DOI: 10.1111/hae.12571] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2014] [Indexed: 01/15/2023]
Abstract
Recurrent gastrointestinal bleeding is one of the most challenging complications encountered in the management of patients with von Willebrand disease (VWD). The commonest cause is angiodysplasia, but often no cause is identified due to the difficulty in making the diagnosis. The optimal treatment to prevent recurrences remains unknown. We performed a retrospective study of VWD patients with occult or angiodysplastic bleeding within the setting of the von Willebrand Disease Prophylaxis Network (VWD PN) to describe diagnostic and treatment strategies. Centres participating in the VWD PN recruited subjects under their care with a history of congenital VWD and gastrointestinal (GI) bleeding due to angiodysplasia, or cases in which the cause was not identified despite investigation. Patients with acquired von Willebrand syndrome or those for whom the GI bleeding was due to another cause were excluded. Forty-eight patients from 18 centres in 10 countries were recruited. Seven individuals had a family history of GI bleeding and all VWD types except 2N were represented. Angiodysplasia was confirmed in 38%, with video capsule endoscopy and GI tract endoscopies being the most common methods of making the diagnosis. Recurrent GI bleeding in VWD is associated with significant morbidity and required hospital admission on up to 30 occasions. Patients were treated with multiple pharmacological agents with prophylactic von Willebrand factor concentrate being the most efficient in preventing recurrence of the GI bleeding. The diagnosis and treatment of recurrent GI bleeding in congenital VWD remains challenging and is associated with significant morbidity. Prophylactic treatment with von Willebrand factor concentrate was the most effective method of preventing recurrent bleeding but its efficacy remains to be confirmed in a prospective study.
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Affiliation(s)
- M Makris
- Sheffield Haemophilia and Thrombosis Centre, Royal Hallamshire Hospital, Sheffield, UK; Department of Cardiovascular Science, University of Sheffield, Sheffield, UK
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Sami SS, Al-Araji SA, Ragunath K. Review article: gastrointestinal angiodysplasia - pathogenesis, diagnosis and management. Aliment Pharmacol Ther 2014; 39:15-34. [PMID: 24138285 DOI: 10.1111/apt.12527] [Citation(s) in RCA: 133] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Revised: 08/14/2013] [Accepted: 09/18/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND Angiodysplasia (AD) of the gastrointestinal (GI) tract is an important condition that can cause significant morbidity and -rarely - mortality. AIM To provide an up-to-date comprehensive summary of the literature evaluating this disease entity with a particular focus on pathogenesis as well as current and emerging diagnostic and therapeutic modalities. Recommendations for treatment will be made on the basis of the current available evidence and consensus opinion of the authors. METHODS A systematic literature search was performed. The search strategy used the keywords 'angiodysplasia' or 'arteriovenous malformation' or 'angioectasia' or 'vascular ectasia' or 'vascular lesions' or 'vascular abnormalities' or 'vascular malformations' in the title or abstract. RESULTS Most AD lesions (54-81.9%) are detected in the caecum and ascending colon. They may develop secondary to chronic low-grade intermittent obstruction of submucosal veins coupled with increased vascular endothelial growth factor-dependent proliferation. Endotherapy with argon plasma coagulation resolves bleeding in 85% of patients with colonic AD. In patients who fail (or are not suitable for) other interventions, treatment with thalidomide or octreotide can lead to a clinically meaningful response in 71.4% and 77% of patients respectively. CONCLUSIONS Angiodysplasia is a rare, but important, cause of both overt and occult GI bleeding especially in the older patients. Advances in endoscopic imaging and therapeutic techniques have led to improved outcomes in these patients. The choice of treatment should be decided on a patient-by-patient basis. Further research is required to better understand the pathogenesis and identify potential therapeutic targets.
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Affiliation(s)
- S S Sami
- Nottingham Digestive Diseases Centre & NIHR Biomedical research Unit, Queens Medical Centre, Nottingham, UK
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Franchini M, Mannucci PM. Von Willebrand disease-associated angiodysplasia: a few answers, still many questions. Br J Haematol 2013; 161:177-82. [PMID: 23432086 DOI: 10.1111/bjh.12272] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The association between angiodysplasia and von Willebrand disease (VWD) has been known for more than 40 years. Bleeding in the gastrointestinal tract associated with angiodysplasia worsens the clinical course of this inherited haemorrhagic disorder and management may become difficult and challenging. Angiodysplasia associated with acquired defects or dysfunctions of von Willebrand factor (VWF) has also been reported in a variety of conditions such as monoclonal gammopathies, Heyde syndrome and in carriers of ventricular assist devices. The most recent advances concerning the mechanistic, clinical and therapeutic aspects of VWD-associated angiodysplasia are summarized in this review, together with the limitations of our knowledge that warrant further research in the frame of international cooperation.
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Affiliation(s)
- Massimo Franchini
- Department of Transfusion Medicine and Haematology, Carlo Poma Hospital, Mantova, Italy
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Recurrent obscure gastrointestinal bleeding: dilemmas and success with pharmacological therapies. Case series and review. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2009; 23:625-31. [PMID: 19816627 DOI: 10.1155/2009/862816] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
The present article describes three difficult cases of recurrent bleeding from obscure causes, followed by a review of the pitfalls and pharmacological management of obscure gastrointestinal bleeding. All three patients underwent multiple investigations. An intervening complicating diagnosis or antiplatelet drugs may have compounded longterm bleeding in two of the cases. A bleeding angiodysplasia was confirmed in one case but was aggravated by the need for anticoagulation. After multiple transfusions and several attempts at endoscopic management in some cases, long-acting octreotide was associated with decreased transfusion requirements and increased hemoglobin levels in all three cases, although other factors may have contributed in some. In the third case, however, the addition of low-dose thalidomide stopped bleeding for a period of at least 23 months.
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Nomikou E, Tsevrenis V, Gafou A, Bellia M, Theodossiades G. Type IIb von Willebrand disease with angiodysplasias and refractory gastrointestinal bleeding successfully treated with thalidomide. Haemophilia 2009; 15:1340-2. [PMID: 19702883 DOI: 10.1111/j.1365-2516.2009.02085.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Korzets A, Gafter U, Chagnac A, Zingerman B, Morduchovitz V, Ori Y. Thalidomide: a treatment option for bleeding GI angiodysplasias in dialysed patients. Clin Kidney J 2008; 1:354-6. [PMID: 25983933 PMCID: PMC4421289 DOI: 10.1093/ndtplus/sfn070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2008] [Accepted: 05/19/2008] [Indexed: 11/14/2022] Open
Affiliation(s)
- Asher Korzets
- Department of Nephrology and Hypertension , Hasharon Hospital , Rabin Medical Center, Petach Tikva, Israel, and Sackler School of Medicine , Tel Aviv University , Tel Aviv , Israel
| | - Uzi Gafter
- Department of Nephrology and Hypertension , Hasharon Hospital , Rabin Medical Center, Petach Tikva, Israel, and Sackler School of Medicine , Tel Aviv University , Tel Aviv , Israel
| | - Avri Chagnac
- Department of Nephrology and Hypertension , Hasharon Hospital , Rabin Medical Center, Petach Tikva, Israel, and Sackler School of Medicine , Tel Aviv University , Tel Aviv , Israel
| | - Boris Zingerman
- Department of Nephrology and Hypertension , Hasharon Hospital , Rabin Medical Center, Petach Tikva, Israel, and Sackler School of Medicine , Tel Aviv University , Tel Aviv , Israel
| | - Valeriya Morduchovitz
- Department of Nephrology and Hypertension , Hasharon Hospital , Rabin Medical Center, Petach Tikva, Israel, and Sackler School of Medicine , Tel Aviv University , Tel Aviv , Israel
| | - Yaacov Ori
- Department of Nephrology and Hypertension , Hasharon Hospital , Rabin Medical Center, Petach Tikva, Israel, and Sackler School of Medicine , Tel Aviv University , Tel Aviv , Israel
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Sohal M, Laffan M. Von Willebrand disease and angiodysplasia responding to atorvastatin. Br J Haematol 2008; 142:308-9. [DOI: 10.1111/j.1365-2141.2008.07005.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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