Preoperative disseminated intravascular coagulation complicated by thoracic aortic aneurysm treated using recombinant human soluble thrombomodulin

Abstract

Rationale: Chronic disseminated intravascular coagulation (DIC) associated with thoracic aortic aneurysm is characterized by enhanced fibrinolysis and is thought to be stable in the compensated/asymptomatic stage, with few bleeding symptoms. However, DIC can lead to decompensated/hemorrhagic stage disseminated intravascular coagulation, resulting in severe bleeding diathesis, and there is currently no established strategy for treatment of DIC in aortic aneurysms. Patient concerns: A 77-year-old woman underwent angiography and cardiac catheterization, before descending aortic replacement surgery. She developed DIC in postprocedure week 2 with extensive, uncontrollable massive subcutaneous hemorrhage. Diagnoses: Her acute-phase DIC score was 7 points, and the risk of mortality within 30 days after surgery according to the JapanSCORE was estimated to be 33.6%. Interventions: Therapy was a combination of recombinant human soluble thrombomodulin (rhTM) and an aortic stent-graft treatment. Outcomes: Short-term improvements were seen in both DIC and bleeding diathesis. The thoracic aortic aneurysm with severe DIC was eventually corrected by administration of rhTM. Lessons: We report the use of rhTM as an effective, novel anticoagulant drug with anti-inflammatory activity for treating DIC with suppressed fibrinolysis, which is typically associated with sepsis. In patients with a high hemorrhagic diathesis, in whom preoperative control of DIC cannot be achieved with conventional anticoagulation and radical surgical repair cannot be performed, a combination of rhTM and endovascular therapy may be a powerful new treatment option.

A case of abdominal aortic aneurysm presenting as symptomatic disseminated intravascular coagulation treated with endovascular aneurysm repair and postoperative administration of Nafamostat mesylate

“…There are several reports of the use of recombinant human soluble thrombomodulin as an anticoagulant therapy for controlling DIC with AAA [ 4 , 5 ]. However, there is little reported experience in administering this drug to DIC patients with underlying diseases other than hematopoietic malignancies, infections, or solid tumors, and its efficacy and safety have not been established for the treatment of aortic aneurysms.…”

Use of Recombinant Human Soluble Thrombomodulin in a Patient with Disseminated Intravascular Coagulation Associated with Abdominal Aortic Aneurysm: A Case Report

“…The cause is that DIC might not be resolved even after the successful exclusion of an aneurysm. 4 ) Moreover, thrombus development or postoperative endoleak can worsen the preexisting DIC. 5 ) Therefore, in certain patients, supportive treatment is thought to manage the coagulopathy.…”

“…There have been three case reports documenting the management of aneurysm-related DIC with the preoperative use of rTM and subsequent aneurysm repair in the pertinent English literature. 4 , 8 , 9 )…”

Therapeutic Strategies for Disseminated Intravascular Coagulation Associated with Aortic Aneurysm

“…Because of the need for intravenous administration and the fact that longterm medication is not covered by public insurance in Japan, recombinant thrombomodulin is often used in the treatment of DIC complicated by aortic aneurysm r perioperative DIC control. Numerous reports have described the efficacy of recombinant thrombomodulin for DIC complicated by aortic aneurysms [90][91][92][93][94]. Although high DIC withdrawal rates and low risk and extent of bleeding complications are advantages, the high cost compared with other agents and the limited duration of administration available in Japan represent distinct disadvantages.…”