1
|
Surgical outcomes in people with hemophilia A taking emicizumab prophylaxis: experience from the HAVEN 1-4 studies. Blood Adv 2022; 6:6140-6150. [PMID: 35939785 PMCID: PMC9768240 DOI: 10.1182/bloodadvances.2022007458] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 07/21/2022] [Accepted: 07/21/2022] [Indexed: 12/30/2022] Open
Abstract
Many people with hemophilia A (PwHA) undergo surgery in their lifetime, often because of complications of their disease. Emicizumab is the first bispecific monoclonal antibody prophylactic therapy for PwHA, and its efficacy and safety have been previously demonstrated; however, there is a need to build an evidence base on the management of PwHA on emicizumab undergoing surgery. Data from the HAVEN 1-4 phase 3 clinical trials were pooled to provide a summary of all minor and major surgeries in PwHA with or without factor VIII (FVIII) inhibitors who were receiving emicizumab prophylaxis. Overall, 233 surgeries were carried out during the HAVEN 1-4 trials: 215 minor surgeries (including minor dental and joint procedures, central venous access device placement or removal, and endoscopies) in 115 PwHA (64 with FVIII inhibitors) and 18 major surgeries (including arthroplasty and synovectomy) in 18 PwHA (10 with FVIII inhibitors). Perioperative hemostatic support was at the discretion of the treating physician. Overall, the median (interquartile range [IQR]) age was 33.5 (13.0-49.0) years and the median (IQR) emicizumab exposure time before surgery was 278.0 (177.0-431.0) days. Among the 215 minor surgeries, 141 (65.6%) were managed without additional prophylactic factor concentrate, and of those, 121 (85.8%) were not associated with a postoperative bleed. The majority (15 of 18 [83.3%]) of major surgeries were managed with additional prophylactic factor concentrate. Twelve (80.0%) of these 15 surgeries were associated with no intraoperative or postoperative bleeds. The data demonstrate that minor and major surgeries can be performed safely in PwHA receiving emicizumab prophylaxis. These trials are registered at www.clinicaltrials.gov as #NCT02622321, #NCT02795767, #NCT02847637, and #NCT03020160.
Collapse
|
2
|
Bohn JP, Fiala A, Bachmann S, Irsara C, Wolf D, Feistritzer C. Major cardiac surgery with recombinant FIX Fc fusion protein replacement in hemophilia B: a case report. Ther Adv Hematol 2022; 13:20406207221104595. [PMID: 35923771 PMCID: PMC9340359 DOI: 10.1177/20406207221104595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 05/16/2022] [Indexed: 01/19/2023] Open
Abstract
The introduction of extended factor IX (FIX) products has significantly facilitated the
treatment of hemophilia B patients. However, optimal perioperative management remains a
topic of hot debate, particularly in surgeries with high bleeding risk. For the first
time, we report here a patient with mild hemophilia B and degenerative aneurysms of aortic
root and ascending aorta undergoing elective Bentall’s operation with full cardiopulmonary
bypass, who was successfully managed with eftrenonacog alfa (Alprolix®), a
recombinant FIX Fc fusion protein (rFIXFc). rFIXFc could safely be monitored using the
Pathromtin SL aPTT-reagent. No significant bleeding was noted intraoperatively despite
systemic heparinization as well as postoperatively. Higher doses of rFIXFc were inevitable
to reach target FIX levels intraoperatively, whereas in the post-surgery setting stable
FIX concentrations were maintained with only few rFIXFc injections facilitating fast wound
healing and remobilization of the patient.
Collapse
Affiliation(s)
- Jan-Paul Bohn
- Department of Internal Medicine V, Hematology and Oncology, Medical University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria
| | - Anna Fiala
- Department of Anesthesiology and Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Sebastian Bachmann
- Central Institute of Clinical and Chemical Laboratory Diagnostics, University Hospital of Innsbruck, Innsbruck, Austria
| | - Christian Irsara
- Central Institute of Clinical and Chemical Laboratory Diagnostics, University Hospital of Innsbruck, Innsbruck, Austria
| | - Dominik Wolf
- Department of Internal Medicine V, Hematology and Oncology, Medical University of Innsbruck, Innsbruck, Austria
| | - Clemens Feistritzer
- Department of Internal Medicine V, Hematology and Oncology, Medical University of Innsbruck, Innsbruck, Austria
| |
Collapse
|
3
|
Mohan K, Broderick JM, Raftery N, McAuley NF, McCarthy T, Hogan N. Perioperative haematological outcomes following total knee arthroplasty in haemophiliacs. J Orthop Surg (Hong Kong) 2021; 29:23094990211033999. [PMID: 34583559 DOI: 10.1177/23094990211033999] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
PURPOSE Patients with haemophilia suffer from recurrent joint haemarthrosis. This can progress to symptomatic arthropathy commonly affecting the knee. While modern coagulation strategies have reduced those proceeding to end-stage arthropathy, total knee arthroplasty (TKA) remains the optimal treatment for some patients. Despite innovation in perioperative haematological management, concerns about the potential for excessive haemorrhage still exist. The aim of this study is to quantify immediate postoperative blood loss and haematological complications in haemophiliacs following TKA. METHODS A retrospective study of patients with haemophilia types A or B who underwent a TKA over a 12-year period at a single institution was conducted. These patients were compared to both a non-haemophiliac control group and to published standards in non-haemophiliacs undergoing TKA. RESULTS Twenty-one TKA procedures in 18 patients (72% haemophilia A, 28% haemophilia B) were suitable for inclusion with a mean age of 44 years. The mean haemoglobin drops at 24 and 48 h postoperatively were 2.7 g/dl and 3.8 g/dl respectively. There was no significant difference in haemoglobin drop at 48 h postoperatively when compared to the non-haemophiliac control group (P = 0.2644). There were no immediate perioperative complications and two patients (9.6%) required postoperative transfusion. CONCLUSION Haemophiliacs undergoing a unilateral primary TKA in a specialised tertiary referral centre appear to have comparable rates of perioperative blood loss when compared to both a non-haemophiliac control group as and published haemostatic standards in non-haemophiliac patients following TKA. Perioperative management with expert orthopaedic and haematological input is recommended to optimise outcomes in this complex patient group.
Collapse
Affiliation(s)
- Kunal Mohan
- Department of Trauma & Orthopaedics, Saint James's Hospital, Dublin, Ireland
| | - James M Broderick
- Department of Trauma & Orthopaedics, Saint James's Hospital, Dublin, Ireland
| | - Nicola Raftery
- Department of Trauma & Orthopaedics, Saint James's Hospital, Dublin, Ireland
| | - Nuala F McAuley
- Department of Trauma & Orthopaedics, Saint James's Hospital, Dublin, Ireland
| | - Tom McCarthy
- Department of Trauma & Orthopaedics, Saint James's Hospital, Dublin, Ireland
| | - Niall Hogan
- Department of Trauma & Orthopaedics, Saint James's Hospital, Dublin, Ireland
| |
Collapse
|
4
|
Totally extraperitoneal inguinal hernia repair in patients with hemophilia and von Willebrand disease. Prospective controlled study. Wideochir Inne Tech Maloinwazyjne 2021; 16:552-559. [PMID: 34691305 PMCID: PMC8512501 DOI: 10.5114/wiitm.2021.103953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 12/23/2020] [Indexed: 11/17/2022] Open
Abstract
Introduction Laparoscopic surgery is associated with several advantages. Surgical procedures in hemophilia or von Willebrand patients without replacement therapy (RT) to correct clotting factor deficiency may result in serious, life-threatening hemorrhagic episodes. Clotting factor concentrates improve hemostatic control but bleeding risk in major invasive procedures remains high. Aim Evaluation of totally extraperitoneal inguinal hernia repair (TEP-IHR) in patients with congenital hemorrhagic disorders (H) and comparison with results for non-hemophiliacs (NH) with regard to bleeding, postoperative pain, hernia recurrence, surgery time, demand for painkillers, hospital stay and recovery time. Material and methods The prospective controlled trial included 67 consecutive male patients scheduled for TEP-IHR between January 2010 and December 2018. Surgery was performed in groups H (n = 22) and NH (n = 45). Full study inclusion criteria were met by 65 patients (22 and 43 in H and NH groups respectively). Follow-up was carried out on the 1st, 2nd, and 7th day and in the 1st and 3rd month postoperatively. Results TEP-IHR was successful for all patients. No life-threatening bleeding occurred and no patient required red blood cell transfusions or reoperation. No hernia recurrence was reported. No statistically significant differences were observed between the groups with regard to surgery duration, postoperative hematoma frequency and demand for painkillers. In the H group, pain intensity was significantly higher during the first postoperative month and hospitalization and recovery were significantly longer. Conclusions TEP-IHR in hemophiliacs with RT is feasible and as effective for preventing hernia recurrence as in NH-patients. In hemophiliacs risk of bleeding complications and demand for painkillers are comparable to non-hemophiliacs although pain is more intense.
Collapse
|
5
|
Ganju N, Rajendran J, Aggarwal M, Dash N. Inhibitor development in mild haemophilia after a major surgery for periampullary cancer (Whipple's procedure) in an elderly man. BMJ Case Rep 2021; 14:e239207. [PMID: 33514621 PMCID: PMC7849882 DOI: 10.1136/bcr-2020-239207] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/23/2020] [Indexed: 01/31/2023] Open
Abstract
Around the world, with the availability of factor concentrates, patients with haemophilia have undergone major and minor surgeries. Inhibitor development in early postoperative period leading to inadequate factor recovery and ongoing bleeding is a nightmare for both operating surgeon as well as haematologists. We describe a case of an elderly man with mild haemophilia A, who was diagnosed with pancreatic carcinoma and underwent Whipple's procedure. After an uneventful procedure, he developed high-titre inhibitors and bleeding a week after surgery posing major challenges in his management. The case highlights the importance of experienced surgeons, trained haematologists, regular monitoring of factor assay/inhibitors, adequate factor and bypassing-agent support while performing such procedures.
Collapse
Affiliation(s)
- Neha Ganju
- Department of Hematology, All India Institute of Medical Sciences, New Delhi, India
| | - Jayapal Rajendran
- Department of Gastrointestinal Surgery and Liver Transplant, All India Institute of Medical Sciences, New Delhi, India
| | - Mukul Aggarwal
- Department of Hematology, All India Institute of Medical Sciences, New Delhi, India
| | - Nihar Dash
- Department of Gastrointestinal Surgery and Liver Transplant, All India Institute of Medical Sciences, New Delhi, India
| |
Collapse
|
6
|
Aquino LM, Ranche FK. Hemophilia presenting as recurrent ocular hemorrhage. GMS OPHTHALMOLOGY CASES 2020; 10:Doc15. [PMID: 32269913 PMCID: PMC7114644 DOI: 10.3205/oc000142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Objective: Patients with hereditary bleeding disorders rarely present with intraocular or orbital hemorrhage as the initial symptom. The presence of such a condition can be easily overlooked when contemplating ophthalmic surgery, and can give rise to intraoperative and postoperative complications. Awareness of such conditions can improve surgical decisions. Methods: This is a case report of an eight-year-old Filipino male who sustained blunt trauma to his right eye, causing traumatic total hyphema with corneal staining. Subretinal hemorrhage was seen on ultrasound. The patient underwent anterior chamber washout with temporary keratoprosthesis and pars plana vitrectomy with silicone oil tamponade. Clearance of the hyphema was noted postoperatively. However, on follow-up after 19 days, the patient presented with recurrence of hyphema, new onset proptosis and peribulbar hemorrhage. Results: Imaging of the orbit revealed new-onset pseudoproptosis with intraocular and peribulbar hemorrhage. A bleeding disorder was suspected at this point. Further probing revealed a family history of prolonged bleeding time in an X-linked genetic inheritance pattern spanning three generations. Laboratory testing of prothrombin, partial thromboplastin, and factor assays were done, which revealed factor VIII deficiency, diagnostic of hemophilia A. No further surgery was done. The patient was given transfusions of fresh frozen plasma, which resolved the hemorrhage. Conclusions: Bleeding disorders present a dilemma in the surgical management of patients. In cases of traumatic hemorrhage, adequate history and physical examination should always be done to rule these out. Surgical outcomes in hemophiliacs can be improved with preoperative prophylactic treatment and close postoperative monitoring and care.
Collapse
Affiliation(s)
- Luis Miguel Aquino
- Department of Ophthalmology and Visual Sciences, Philippine General Hospital, Manila, Philippines
| | - Felice Katrina Ranche
- Department of Ophthalmology and Visual Sciences, Philippine General Hospital, Manila, Philippines
| |
Collapse
|
7
|
Vascularized Free Tissue Transfer in a Patient with Hemophilia B: Case Report and Literature Review. Case Rep Surg 2020; 2019:5430786. [PMID: 31976116 PMCID: PMC6954477 DOI: 10.1155/2019/5430786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Accepted: 12/10/2019] [Indexed: 01/19/2023] Open
Abstract
Hemophilia is a blood disorder characterized by impairment of the coagulation cascade leading to an increased bleeding risk (Kauffman, 2014). As such, surgical management of these patients can become difficult and well-defined surgical guidelines are not yet in place (Assoumane et al., 2017). Close monitoring of perioperative factor levels may be even more crucial for those undergoing microvascular free tissue transfer. This is because either a hypercoagulable or hypocoagulable bleeding state has the potential to further increase the risk of vascular compromise to the flap. We report a successful case of mandibular reconstruction using a free fibular flap in a patient with severe hemophilia B and the protocols we used, as well as a review of the literature of similar cases. In the literature, we identified 6 cases of microvascular free tissue transfer in patients with hemophilia; two of these cases had complications which were both related to excess bleeding. It is crucial that these cases be managed in a multidisciplinary fashion in close consultation with a hematologist. The role of venothromboembolism (VTE) prophylaxis in the hemophilic patient undergoing free tissue transfer is discussed.
Collapse
|
8
|
Neufeld EJ, Solimeno L, Quon D, Walsh C, Seremetis S, Cooper D, Iyer NN, Hoxer CS, Giangrande P. Perioperative management of haemophilia B: A critical appraisal of the evidence and current practices. Haemophilia 2017; 23:821-831. [PMID: 28752639 DOI: 10.1111/hae.13279] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2017] [Indexed: 01/19/2023]
Affiliation(s)
| | - L. Solimeno
- IRCCS Cà Granda Foundation; Maggiore Hospital; Milan Italy
| | - D. Quon
- Orthopaedic Hemophilia Treatment Center; Los Angeles USA
| | - C. Walsh
- Mount Sinai Hospital; New York USA
| | | | | | | | | | - P. Giangrande
- Oxford University Hospitals NHS Trust; Oxford Haemophilia Centre; Oxford UK
| |
Collapse
|
9
|
Panovski MJ, Fildishevski IV, Ognjenovic LL, Dejanova-Ilijevska VI. New Surgical Technologies Could Facilitate Surgical Hemostasis in Hemophilic Patients. Open Access Maced J Med Sci 2017; 5:295-298. [PMID: 28698745 PMCID: PMC5503725 DOI: 10.3889/oamjms.2017.062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Revised: 04/02/2017] [Accepted: 04/05/2017] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND It's assumed that surgery in haemophilia can be accomplished these days safely. AIM The aim of this study was to investigate the influence of new surgical technologies in the perioperative management and outcome of surgical procedures in haemophiliacs. METHODS Two patients with mild haemophilia A underwent surgery (laparoscopic appendectomy and inguinal hernia repair). In both patients, the replacement therapy, with factor VIII, started 30 min before surgery. We used the available surgical technologies and techniques with a proven value in the best clinical practice, to achieve proper and permanent hemostasis. Postoperatively, the replacement therapy and thromboembolic prophylaxis was continued according to the international guidelines for the management of haemophilia. RESULTS The operative and post-operative periods were uneventful. No significant differences were found in the operation time in our hemophilic patients versus non-hemophilic patients. Significant differences related to the hospital stay duration were found in both patients compared with controls, due to the necessary replacement therapy. CONCLUSION With new surgical technologies, proper and permanent hemostasis can be achieved, without prolonging the operation time.
Collapse
Affiliation(s)
- Milcho J. Panovski
- University Clinic for Digestive Surgery, Medical Faculty, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
| | - Igor V. Fildishevski
- University Clinic for Digestive Surgery, Medical Faculty, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
| | - Ljubomir Lj. Ognjenovic
- University Clinic for Digestive Surgery, Medical Faculty, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
| | - Violeta I. Dejanova-Ilijevska
- National Center for Hemophilia, Republic Institute for Transfusiology, Vodnjanska 17, Skopje 1109, Republic of Macedonia
| |
Collapse
|
10
|
WATTS RG, COOK RP. Operative management and outcomes in children with congenital bleeding disorders: a retrospective review at a single haemophilia treatment centre. Haemophilia 2011; 18:421-5. [DOI: 10.1111/j.1365-2516.2011.02667.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
11
|
Aryal KR, Wiseman D, Siriwardena AK, Bolton-Maggs PHB, Hay CRM, Hill J. General Surgery in Patients With a Bleeding Diathesis: How We Do It. World J Surg 2011; 35:2603-10. [DOI: 10.1007/s00268-011-1265-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
12
|
Obitko-Pludowska A, Laguna P, Adamowicz-Salach A, Brzewski M, Del Campo KS. Haemothorax in children with congenital coagulopathy. Haemophilia 2010; 16:688-691. [PMID: 20398069 DOI: 10.1111/j.1365-2516.2010.02209.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
|
13
|
Ng SSM, Wong WS, Li JCM, Lee JFY. Postpolypectomy bleeding secondary to undiagnosed haemophilia B in an octogenarian. Int J Clin Pract 2010; 64:119-21. [PMID: 20089029 DOI: 10.1111/j.1742-1241.2005.00809.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
|
14
|
Transplantation rénale chez un patient hémophile A. Transfus Clin Biol 2009; 16:471-3. [DOI: 10.1016/j.tracli.2009.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2008] [Accepted: 09/22/2009] [Indexed: 11/19/2022]
|
15
|
HERMANS C, ALTISENT C, BATOROVA A, CHAMBOST H, DE MOERLOOSE P, KARAFOULIDOU A, KLAMROTH R, RICHARDS M, WHITE B, DOLAN G. Replacement therapy for invasive procedures in patients with haemophilia: literature review, European survey and recommendations. Haemophilia 2009; 15:639-58. [DOI: 10.1111/j.1365-2516.2008.01950.x] [Citation(s) in RCA: 113] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
|
16
|
Slaoui M, Lambert T, Stieltjes N, Claeyssens S, Borel-Derlon A. Intestinal surgery with activated recombinant factor VII prophylaxis in patients with haemophilia A and high responding inhibitors. Blood Coagul Fibrinolysis 2004; 15:687-91. [PMID: 15613924 DOI: 10.1097/00001721-200412000-00009] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Five patients with severe haemophilia A and high responding inhibitors underwent laparoscopic or open surgery on the digestive tract (appendicectomy, cholecystectomy, partial colectomy, or haemorrhoidectomy) with recombinant activated factor VII (rFVIIa) prophylaxis. rFVIIa was administered at a dose of 92-127 mug/kg prior to surgery and then every 2 h for 18-56 h before increasing the dosing interval. One patient was switched to a continuous infusion after 48 h of rFVIIa boluses. rFVIIa treatment lasted between 5 and 14 days in four patients, with good or excellent efficacy (total dose, 3.13-9.28 mg/kg). The fifth patient, who underwent surgery for prolapsed haemorrhoids, bled on day 6 and day 10 after the procedure, despite a satisfactory prothrombin time and factor VII coagulant level. The rFVIIa dose regimen was increased after the second bleeding episode, then the bleeding rapidly ceased after this modification to the treatment regimen. The total dose of rFVIIa used was 12.65 mg/kg, and treatment lasted 17 days. Antifibrinolytic treatment was used concomitantly in all five patients. Clinical and biological tolerability was excellent, and no increase in the anti-factor VIII inhibitor titre was observed. These results suggest that rFVIIa prophylaxis is effective in haemophilia A patients with factor VIII inhibitors who are undergoing elective or emergency intestinal surgery. Further studies are required to optimize the dose regimen and treatment period according to the surgical indication and technique.
Collapse
Affiliation(s)
- Mounia Slaoui
- Haemophilia Centre, University Hospital of Caen, France
| | | | | | | | | |
Collapse
|