Management of elective procedures in low von Willebrand factor patients in the LoVIC study

Abstract

Background Most individuals with mild to moderate reductions in plasma von Willebrand factor (VWF) levels do not demonstrate increased bleeding. However, some patients with plasma VWF levels of 30–50 IU/dl do have a significant bleeding phenotype. Management of these “low VWF” patients, who may have significant bleeding scores >10, around times of elective procedures continues to pose a common clinical challenge because of a lack of evidence. Objective To investigate the safety and efficacy of different periprocedural management options for adult patients with low VWF. Methods Treatment and outcomes were retrospectively reviewed for 160 invasive procedures performed in 60 patients with well characterized low VWF enrolled in the previously described Low Von Willebrand factor Ireland Cohort study. Results We demonstrate that 1‐desamino‐8‐D‐arginine vasopressin is efficacious in preventing bleeding for both minor or major elective procedures in adult low VWF patients, even in those with significant bleeding histories. In addition, tranexamic acid alone is effective for low VWF patients undergoing nondental minor procedures. Importantly, age‐related increases in plasma VWF:antigen levels above 50 IU/dl were not necessarily associated with complete correction of bleeding phenotype. Procedure‐related bleeding complications were increased in low VWF patients who did not receive any hemostatic cover before their procedure. Conclusion Elective procedures in adult patients with low VWF should be managed in liaison with a comprehensive care tertiary referral center so that personalized treatment plans may be implemented before all minor or major elective procedures.

Low von Willebrand Disease: A Bleeding Disorder of Unknown Cause?

“…12,59 Consistent with these findings, Doherty et al went on to use desmopressin AE TA to manage 99 elective dental and minor surgical procedures. 58 Even though all these low VWF patients had significant bleeding histories, bleeding complications were observed in only one single dental extraction. 58 Cumulatively, these laboratory and clinical data therefore suggest that desmopressin has an important role to play in the management of low VWF.…”

“…[55][56][57] Doherty et al recently reported on the management of elective procedures in adult low VWF patients in the LoVIC study. 58 This retrospective review included 160 invasive procedures (40 dental, 109 minor, and 11 major procedures) performed in 60 patients. Notably, these low VWF patients all had abnormal ISTH BAT scores, with 21/60 (35%) patients having BAT scores greater than 10.…”

“…Notably, these low VWF patients all had abnormal ISTH BAT scores, with 21/60 (35%) patients having BAT scores greater than 10. 58 TA treatment alone, commencing on the evening prior to the elective procedure, was used for 25% of dental procedures and 23% of the minor elective procedures examined. Bleeding complications were seen in only three of these procedures managed with TA alone.…”

Enhanced VWF clearance in low VWF pathogenesis: limitations of the VWFpp/VWF:Ag ratio and clinical significance

“… 11 Desmopressin (DDAVP) trials were performed in 75 patients with low VWF. 15 In brief, DDAVP (0.3 μg/kg; maximum dose capped at 27 μg/kg) was administered IV, and blood samples were drawn for VWF:Ag, VWF:RCo, and FVIII:C at baseline (T0), 1 hour (T+1), and 4 hours (T+4). In a subset of 24 patients, additional samples were drawn at 24 hours (T+24).…”

Bleeding disorders in implant dentistry: a narrative review and a treatment guide

“…As part of a prospective study, 40 dental procedures (mostly single tooth extractions) were performed under local hemostatic measures in addition to systemic administration of tranexamic acid (1 g/3 × days) in 25% of the cases and desmopressin (0.3 μg/kg BW) in 72.5% of the cases. As a result, only 10% of the treated patients showed post-interventional bleeding events [ 13 ].…”