[Acute arterial thrombosis in hemophilia with inhibitory antibodies]

The authors demonstrate an importance of personalized approach to perioperative hemostatic therapy in a 48-year-old patient with hemophilia A and inhibitory antibodies. Laparoscopic hernia repair and extraction of 15 decayed teeth were performed. Hemostatic therapy included AICC and rFVIIa. Postoperative period was complicated by acute thrombosis of splenic artery and partial spleen infarction. An essential factor in splenic artery thrombosis was increase in blood coagulation potential under rFVIIa administration and depletion of fibrinolytic system (prolongation of XIIa-dependent fibrinolysis from 25 to 75 min) and antithrombin III decrease up to 81%. Cancellation of hemostatic therapy under TEG control ensured fast regression of arterial thrombosis and preservation of spleen. Individual characteristics of patients (compensatory mechanisms of coagulation, comorbidities, clinical changes) should be considered when prescribing hemostatic therapy in hemophilia patients. Perioperative control of all possible coagulation tests (routine and integral) is required for individual selection of hemostatic therapy and decrease of the risk of hemorrhagic and thrombotic complications.

[Inhibitory and mild forms of hemophilia: diagnostic difficulties, surgical complications]

AIM

To identify patients with hemophilia who have a high risk of postoperative hemorrhagic complications.

MATERIAL AND METHODS

Prospective trial included 69 patients aged 18-71 years (median 29) with congenital hemophilia A and B. They underwent elective and emergency treatment for abdominal and thoracic pathology at the National Medical Research Center for Hematology in 2011-2016. Patients with mild and inhibitory forms of hemophilia were compared with those with severe and moderate forms of hemophilia. There were 50 (73%) patients with severe and moderate forms of hemophilia, 8 (11%) with inhibitory and 11 (16%) patients with mild form. Emergency operations were performed in 18 cases, elective - in 51.

RESULTS

Inhibitory form of hemophilia is associated with 1.5 times higher (95% CI, 1.1-3.0) risk of hemorrhagic postoperative complications and death and 3,5 times higher (95% CI 1.7-5.9) risk of redo surgery compared with severe and moderate forms (p<0.05). Risk of hemorrhagic postoperative complications is also higher in patients with mild form of hemophilia compared with severe and moderate forms (1/6 vs. 1/50; p=0.05).

CONCLUSION

The risk of postoperative hemorrhagic complications is significantly higher in inhibitory and mild hemophilia compared with severe and moderate forms and associated with hemostatic therapy defects and inadequate assessment of hemostatic disorders. Long-standing haemorrhagic syndrome should be followed by blood clotting system analysis including evaluation of procoagulant activity, presence of inhibitor, and thromboelastography. Decreased levels of albumin (by 2.9-8.6% in our trial) and cholesterol (by 6.5-54.8%) reflects impaired liver function and is sign of unfavorable prognosis. This finding should be considered for surgery and therapy of hemorrhagic manifestations.