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Perioperative Management of Antiphospholipid Antibody-Positive Patients

  • SURGERY AND PERIOPERATIVE CARE (CR MACKENZIE AND SM GOODMAN, SECTION EDITORS)
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Abstract

Perioperative management of antiphospholipid antibody (aPL)-positive patients is challenging because there are limited data on which to base recommendations. This population of patients is at high risk of thrombosis at the time of surgery; it is essential that medical and surgical teams devise a plan to minimize the patient’s risk of thrombosis without increasing bleeding risk. During the perioperative period, pharmacological methods should be combined with physical methods, patients should be closely observed for thrombosis, and any deviation from the normal course should be considered a potential aPL-related event. Periods without anticoagulation should be kept to an absolute minimum for aPL-positive patients with a history of thrombosis and physicians should keep in mind that thrombosis can occur despite optimum prophylaxis.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Miyakis S, Lockshin MD, Atsumi T, et al. International consensus statement on an update of the classification criteria for definite antiphospholipid syndrome (APS). J Thromb Haemost. 2006;4:295–306.

    Article  CAS  PubMed  Google Scholar 

  2. Saunders KH, Erkan D. Perioperative management of antiphospholipid antibody positive patients during non-cardiac surgeries. In: Mandell BF, editor. Perioperative management of the patient with rheumatic disease. 1st ed. New York: Springer; 2012. p. 91–107. This book chapter is a review of the perioperative management of aPL-positive patients undergoing noncardiac surgery. It provides a detailed analysis of the literature and offers expert recommendations. It also includes information on the role of aspirin, hydroxychloroquine, and statins during the perioperative period.

    Google Scholar 

  3. Asherson RA, Cervera R, de Groot PG, for the Catastrophic Antiphospholipid Syndrome Registry Project Group, et al. Catastrophic antiphospholipid syndrome: international consensus statement on classification criteria and treatment guidelines. Lupus. 2003;12:530–4.

    Article  CAS  PubMed  Google Scholar 

  4. Petri M. Epidemiology of the antiphospholipid antibody syndrome. J Autoimmun. 2000;15:145–51.

    Article  CAS  PubMed  Google Scholar 

  5. Vila P, Hernández MC, López-Fernández MF, Batlle J. Prevalence, follow-up and clinical significance of the anticardiolipin antibodies in normal subjects. Thromb Haemost. 1994;72:209–13.

    CAS  PubMed  Google Scholar 

  6. Erkan D, Lockshin M. New approaches for managing antiphospholipid syndrome. Nat Clin Pract Rheumatol. 2009;5:160–70.

    Article  PubMed  Google Scholar 

  7. Fischetti F, Durigutto P, Pellis V, et al. Thrombus formation induced by antibodies to beta2-glycoprotein I is complement dependent and requires a priming factor. Blood. 2005;106:2340–6.

    Article  CAS  PubMed  Google Scholar 

  8. Kaul M, Erkan D, Sammaritano L, Lockshin MD. Assessment of the 2006 revised antiphospholipid syndrome classification criteria. Ann Rheum Dis. 2007;66:927–30.

    Article  PubMed Central  PubMed  Google Scholar 

  9. Erkan D, Yazici Y, Peterson MG, Sammaritano L, Lockshin MD. A cross-sectional study of clinical thrombotic risk factors and preventive treatments in antiphospholipid syndrome. Rheumatology (Oxford). 2002;41:924–9.

    Article  CAS  Google Scholar 

  10. Asherson RA, Cervera R, Piette JC, et al. Catastrophic antiphospholipid syndrome: clues to the pathogenesis from a series of 80 patients. Medicine (Baltimore). 2001;80:355–76.

    Article  CAS  Google Scholar 

  11. Bartholomew JR. Perioperative management of anticoagulation in the patient with the antiphospholipid syndrome in cardiac surgery and cardiac interventions. In: Mandell BF, editor. Perioperative management of the patient with rheumatic disease. 1st ed. New York: Springer; 2012. p. 109–27. This book chapter is a review of the peioperative management of patients with APS undergoing cardiac procedures.

    Google Scholar 

  12. Avcin T, Toplak N. Antiphospholipid antibodies in response to infection. Curr Rheumatol Rep. 2007;9:212–8.

    Article  CAS  PubMed  Google Scholar 

  13. Galli M, Luciani D, Bertolini G, Barbui T. Lupus anticoagulants are stronger risk factors for thrombosis than anticardiolipin antibodies in the antiphospholipid syndrome: a systematic review of the literature. Blood. 2003;101:1827–32.

    Article  CAS  PubMed  Google Scholar 

  14. Pengo V, Biasiolo A, Gresele P, for the Participating Centres of Italian Federation of Thrombosis Centres (FCSA), et al. Survey of lupus anticoagulant diagnosis by central evaluation of positive plasma samples. J Thromb Haemost. 2007;5:925–30.

    Article  CAS  PubMed  Google Scholar 

  15. Pengo V, Tripodi A, Reber G, for the Subcommittee on Lupus Anticoagulant/Antiphospholipid Antibody of the Scientific and Standardisation Committee of the International Society on Thrombosis and Haemostasis, et al. Update of the guidelines for lupus anticoagulant detection. J Thromb Haemost. 2009;7:1737–40.

    Article  CAS  PubMed  Google Scholar 

  16. Trappe R, Loew A, Thuss-Patience P, Dörken B, Riess H. Successful treatment of thrombocytopenia in primary antiphospholipid antibody syndrome with the anti-CD20 antibody rituximab—monitoring of antiphospholipid and anti-GP antibodies: a case report. Ann Hematol. 2006;85:134–5.

    Article  CAS  PubMed  Google Scholar 

  17. Galli M, Finazzi G, Barbui T. Thrombocytopenia in the antiphospholipid syndrome. Br J Haematol. 1996;93:1–5.

    Article  CAS  PubMed  Google Scholar 

  18. Erkan D, Bateman H, Lockshin MD. Lupus anticoagulant-hypoprothrombinemia syndrome associated with systemic lupus erythematosus: report of 2 cases and review of literature. Lupus. 1999;8:560–4.

    Article  CAS  PubMed  Google Scholar 

  19. Erkan D, Leibowitz E, Berman J, Lockshin MD. Perioperative medical management of antiphospholipid syndrome: hospital for special surgery experience, review of literature, and recommendations. J Rheumatol. 2002;29:843–9.

    PubMed  Google Scholar 

  20. Vinet E, Rich E, Senécal JL. Thromboembolism complicating the treatment of lupus anticoagulant hypoprothrombinemia syndrome. J Rheumatol. 2006;33:2088–90.

    PubMed  Google Scholar 

  21. Simel D, St. Claire EW, Adams J, Greenberg C. Correction of hypothrombinemia by immunosuppressive treatment of lupus anticoagulant-hypoprothrombinemia syndrome. Am J Med. 1987;83:563–6.

    Article  CAS  PubMed  Google Scholar 

  22. Asherson RA, Chan JK, Harris EN, Gharavi AE, Hughes GR. Anticardiolipin antibody, recurrent thrombosis, and warfarin withdrawal. Ann Rheum Dis. 1985;44:823–5.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  23. Palareti G, Legnani C, Guazzaloca G, et al. Activation of blood coagulation after abrupt or stepwise withdrawal of oral anticoagulants—a prospective study. Thromb Haemost. 1994;72:222–6.

    CAS  PubMed  Google Scholar 

  24. Yamamoto T, Ito M, Nagata S, et al. Catastrophic exacerbation of antiphospholipid syndrome after lung adenocarcinoma biopsy. J Rheumatol. 2000;27:2035–7.

    CAS  PubMed  Google Scholar 

  25. Chouhan VD, Comerota AJ, Sun L, Harada R, Gaughan JP, Rao AK. Inhibition of tissue factor pathway during intermittent pneumatic compression: a possible mechanism for antithrombotic effect. Arterioscler Thromb Vasc Biol. 1999;19:2812–7.

    Article  CAS  PubMed  Google Scholar 

  26. Kakkos SK, Caprini JA, Geroulakos G, Nicolaides AN, Stansby GP, Reddy DJ. Combined intermittent pneumatic leg compression and pharmacological prophylaxis for prevention of venous thromboembolism in high-risk patients. Cochrane Database Syst Rev. 2008;4, CD005258.

    PubMed  Google Scholar 

  27. Sevitt S. Pathology and pathogenesis of deep vein thrombosis. In: Bergan J, Yao J, editors. Venous problems. Chicago: Year Book; 1976. p. 257–69.

    Google Scholar 

  28. Kraai EP, Lopes RD, Alexander JH, Garcia D. Perioperative management of anticoagulation: guidelines translated for the clinician. J Thromb Thrombolysis. 2009;28:16–22.

    Article  PubMed  Google Scholar 

  29. Geerts WH, Bergqvist D, Pineo GF, for the American College of Chest Physicians, et al. Prevention of venous thromboembolism: American College of Chest Physicians evidence-based clinical practice guidelines (8th edition). Chest. 2008;133:381S–453.

    Article  CAS  PubMed  Google Scholar 

  30. Douketis JD, Berger PB, Dunn AS, for the American College of Chest Physicians, et al. The perioperative management of antithrombotic therapy: American College of Chest Physicians evidence-based clinical practice guidelines (8th edition). Chest. 2008;133:299S–339.

    Article  CAS  PubMed  Google Scholar 

  31. Faltas B, Kouides PA. Update on perioperative bridging in patients on chronic oral anticoagulation. Expert Rev Cardiovasc Ther. 2009;7:1533–9.

    Article  PubMed  Google Scholar 

  32. Price EA, Jin J, Nguyen HM, Krishnan G, Bowen R, Zehnder JL. Discordant aPTT and anti-Xa values and outcomes in hospitalized patients treated with intravenous unfractionated heparin. Ann Pharmacother. 2013;47(2):151–8.

    Article  PubMed  Google Scholar 

  33. Muhsin SA, Khianey R, Erkan D. Comment: discordant aPTT and anti-Xa values and outcomes in hospitalized patients treated with intravenous unfractionated heparin. Ann Pharmacother. 2013;47(9):1239–40.

    Article  PubMed  Google Scholar 

  34. Horlocker TT, Heit JA. Low molecular weight heparin: biochemistry, pharmacology, perioperative prophylaxis regimens, and guidelines for regional anesthetic management. Anesth Analg. 1997;85:874–5.

    CAS  PubMed  Google Scholar 

  35. Horlocker TT, Wedel DJ, Rowlingson JC, et al. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine evidence-based guidelines (third edition). Reg Anesth Pain Med. 2010;35:64–101.

    Article  CAS  PubMed  Google Scholar 

  36. Silverberg M, Erkan D, Lockshin MD. Hemorrhage in the antiphospholipid syndrome: the challenge of anticoagulation. Arthritis Rheum. 2002;46:S52.

    Article  Google Scholar 

  37. Devereaux PJ, Mrkobrada M, Sessler DI, et al. Aspirin in patients undergoing noncardiac surgery. N Engl J Med. 2014.

  38. Bobba RS, Crowther MA. Perioperative management of the patient with immune thrombocytopenic purpura de novo and the thrombocytopenia of antiphospholipid antibody syndrome. In: Mandell BF, editor. Perioperative management of the patient with rheumatic disease. 1st ed. New York: Springer; 2012. p. 129–35.

    Google Scholar 

  39. Tenedios F, Erkan D, Vega J, Ramon G, Kozora E, Lockshin MD. Rituximab in Antiphospholipid Syndrome (RITAPS)—a pilot open-label phase II prospective trial for non-criteria manifestations of antiphospholipid antibodies. Arthritis Rheum. 2013;65(2):464–71.

    Article  Google Scholar 

  40. Raflores MB, Kaplan RB, Spero JA. Pre-operative management of a patient with hypoprothrombinemialupus anticoagulant syndrome. Thromb Haemost. 2007;98:248–50.

    CAS  PubMed  Google Scholar 

  41. Drazin D, Westley Phillips H, Shirzadi A, Drazin N, Schievink W. Neurosurgical management for complicated catastrophic antiphospholipid syndrome. J Clin Neurosci. 2014;21(4):680–3.

    Article  PubMed  Google Scholar 

  42. Erkan D. Therapeutic and prognostic considerations in catastrophic antiphospholipid syndrome. Autoimmun Rev. 2006;6:98–103.

    Article  CAS  PubMed  Google Scholar 

  43. Deane KD, West SG. Antiphospholipid antibodies as a cause of pulmonary capillaritis and diffuse alveolar hemorrhage: a case series and literature review. Semin Arthritis Rheum. 2005;35:154–65.

    Article  PubMed  Google Scholar 

  44. Vigué B. Bench-to-bedside review: optimising emergency reversal of vitamin K antagonists in severe haemorrhage—from theory to practice. Crit Care. 2009;13:209.

    Article  PubMed Central  PubMed  Google Scholar 

  45. Cerrato D, Ariano C, Fiacchino F. Deep vein thrombosis and low-dose heparin prophylaxis in neurosurgical patients. J Neurosurg. 1978;49:378–81.

    Article  CAS  PubMed  Google Scholar 

  46. Iorio A, Agnelli G. Low-molecular-weight and unfractionated heparin for prevention of venous thromboembolism in neurosurgery: a meta-analysis. Arch Intern Med. 2000;160:2327–32.

    Article  CAS  PubMed  Google Scholar 

  47. Cheng JS, Arnold PM, Anderson PA, Fischer D, Dettori JR. Anticoagulation risk in spine surgery. Spine (Phila Pa 1976). 2010;35:S117–24.

    Article  Google Scholar 

  48. Stone JH, Amend WJ, Criswell LA. Antiphospholipid antibody syndrome in renal transplantation: occurrence of clinical events in 96 consecutive patients with systemic lupus erythematosus. Am J Kidney Dis. 1999;34:1040–7.

    Article  CAS  PubMed  Google Scholar 

  49. McIntyre JA, Wagenknecht DR. Antiphospholipid antibodies. Risk assessments for solid organ, bone marrow, and tissue transplantation. Rheum Dis Clin N Am. 2001;27:611–31.

    Article  CAS  Google Scholar 

  50. Raklyar I, DeMarco J, Wu J, Light J, Timbil S, Weinstein A. Anticardiolipin antibody positivity correlates with poor graft survival in renal transplantation for systemic lupus erythematosus [abstract]. Arthritis Rheum. 2005;52:S384–5.

    Google Scholar 

  51. Canaud G, Bienaimé F, Noël LH, et al. Severe vascular lesions and poor functional outcome in kidney transplant recipients with lupus anticoagulant antibodies. Am J Transplant. 2010;10(9):2051–60.

    Article  CAS  PubMed  Google Scholar 

  52. Wagenknecht DR, Becker DG, LeFor WM, McIntyre JA. Antiphospholipid antibodies are a risk factor for early renal allograft failure. Transplantation. 1999;68:241–6.

    Article  CAS  PubMed  Google Scholar 

  53. Forman JP, Lin J, Pascual M, Denton MD, Tolkoff-Rubin N. Significance of anticardiolipin antibodies on short and long term allograft survival and function following kidney transplantation. Am J Transplant. 2004;4:1786–91.

    Article  CAS  PubMed  Google Scholar 

  54. Furmańczyk-Zawiska A, Bączkowska T, Sadowska A, Szmidt J, Chmura A, Durlik M. Antiphospholipid antibodies in renal allograft recipients. Transplant Proc. 2013;45(4):1655–60.

    Article  PubMed  Google Scholar 

  55. Vaidya S, Sellers R, Kimball P, et al. Frequency, potential risk and therapeutic intervention in end-stage renal disease patients with antiphospholipid antibody syndrome: a multicenter study. Transplantation. 2000;69:1348–52.

    Article  CAS  PubMed  Google Scholar 

  56. Domingues V, Dadhania D, Hartona C, Pastore R, Erkan D. Hospital for Special Surgery—Cornell Protocol for Antiphospholipid Antibody Positive Patients Undergoing Renal Transplantation. 14th International Congress on aPL Abstract Book 2013;316:70.

  57. Cherian J, Gertner E. Recurrent pulmonary embolism despite inferior vena cava filter placement in patients with the antiphospholipid syndrome. J Clin Rheumatol. 2005;11:56–8.

    Article  PubMed  Google Scholar 

  58. Decousus H, Leizorovicz A, Parent F, et al. A clinical trial of vena caval filters in the prevention of pulmonary embolism in patients with proximal deep-vein thrombosis. Prévention du Risque d’Embolie Pulmonaire par Interruption Cave Study Group. N Engl J Med. 1998;338:409–15.

    Article  CAS  PubMed  Google Scholar 

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Compliance with Ethics Guidelines

Conflict of Interest

Doruk Erkan declares that he has a paid consultancy with Alexion, and grants or grants pending from the Lupus Clinical Trials Consortium, the New York Community Trust, and Eli Lilly and Company. He has also received a speaker’s bureau honorarium from HGS.

Katherine Saunders and Michael Lockshin declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

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Authors and Affiliations

  1. Department of Medicine, New York-Presbyterian Hospital, 525 East 68th Street, Box 130, New York, NY, 10065, USA

    Katherine H. Saunders

  2. Barbara Volcker Center for Women and Rheumatic Diseases, Hospital for Special Surgery, Weill Medical College of Cornell University, 535 East 70th Street, New York, NY, 10021, USA

    Doruk Erkan & Michael D. Lockshin

Authors
  1. Katherine H. Saunders
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  2. Doruk Erkan
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  3. Michael D. Lockshin
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Correspondence to Doruk Erkan.

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This article is part of the Topical Collection on Surgery and Perioperative Care

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Saunders, K.H., Erkan, D. & Lockshin, M.D. Perioperative Management of Antiphospholipid Antibody-Positive Patients. Curr Rheumatol Rep 16, 426 (2014). https://doi.org/10.1007/s11926-014-0426-7

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