Perioperative management of patients with antiphospholipid syndrome: a single-center experience

Abstract

The objective was to describe the management and risk factors for complications of antiphospholipid syndrome (APS) patients who underwent a surgical procedure in a single center. We reviewed medical records of all patients with primary or secondary APS who underwent an elective surgery during a 6-year period. Demographical data, management of anticoagulation and complications were recorded. We identified 43 patients, mean age 37.9 ± 8.9 years, who underwent a total of 48 elective surgeries. All patients had history of at least one thrombotic event and were under vitamin K antagonists. Before surgery, all patients received bridging therapy with intravenous infusion of heparin or low molecular weight heparin (LMWH). Among the LMWH group, 36 had a full anticoagulation regimen and nine prophylactic doses. In 62% of the surgeries, we identified an optimal management of periprocedural anticoagulation according to guidelines. Overall six patients had severe bleeding and three thrombotic complications (full anticoagulation regimen n = 2 and prophylactic dose group n = 1). Patients with optimal management of anticoagulation experienced less thrombotic and hemorrhagic complications (7 vs. 33%; OR 0.14, 95% CI 0.02-0.81; p = 0.040) and patients with INR ≤1.5 at surgery had fewer episodes of major bleeding (6 vs. 29%; OR 0.19, 95% CI 0.02-0.98; p = 0.050). All three thrombotic events occurred in patients with INR ≤1.5. Proper management of anticoagulation based on guidelines is associated with less complications in patients with APS. Notwithstanding the proper use of bridging therapy, some patients may develop thrombotic complications.

Severe thrombotic events associated with pre-procedural interruption of anticoagulation in systemic lupus erythematosus with secondary antiphospholipid syndrome: Cases and literature review

“…Atisha–Fregosos et al studied risk of thrombotic events with standard of care bridging therapy in APS patient undergoing non-cardiac surgery. 11 In this retrospective study, 17 (35%) cases were triple positive. In all, there were three patients with thrombotic events, one of which occurred in a triple positive patient.…”

“…The time period without any form of anticoagulation ranged from 12 to 60 h. Although the interval between thrombotic event and cessation of anticoagulation is not reported for all nine cases, the severity of the thrombotic events and speed in which they occurred in our cases, less than 24 h of anticoagulation interruption, demonstrates that timing of anticoagulation suspension is crucial in APS and every effort should be made to keep periods without anticoagulation to an absolute minimum. 13 ACCP and NICE guideline’s suggest bridging therapy with full anticoagulation, UFH or LMWH, which must be discontinued 4–24 h before surgery respectively, and restart of full anticoagulation within 24–48 h 11 Unfortunately, this may still be too conservative in triple positive APS. Case 1 and 3 had severe thrombotic events within 24 h of their last full dose LMWH and Case 2 was admitted with CAPS less than 24 h after her procedure.…”

Spontaneous Hematoma of Upper Extremities in a Patient with Antiphospholipid Antibody Syndrome: A Case Report

“…In high-risk bleeding surgery, the perioperative INR is recommended to be maintained under 1.5. However, for patients with previous thrombotic events, higher INR values, sometimes even over 3.0, are recommended and close monitoring is more important in these cases [10,11]. As such, patients with underlying APS require even more attention.…”

Perioperative Management of Patients with Inflammatory Rheumatic Diseases Undergoing Major Orthopaedic Surgery: A Practical Overview

“…3 ). Despite the proper use of bridging therapy, some patients may develop thrombotic complications, particularly those with concomitant SLE [ 122 ]. Until a few years ago, vitamin K antagonists were the outpatient anticoagulants of choice, but many newer anticoagulants are now available [ 123 ].…”