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. 2020 Feb 4;6(1):7.
doi: 10.1186/s40981-020-0316-0.

Coagulation assessment with thromboelastography during abdominal endovascular aneurysm repair in a patient with hemophilia A

Kazuki Sato  1 , Nobuyuki Katori  2 , Yoshifumi Suga  1 , Shuya Kiyama  1 , Shoichi Uezono  1
Affiliations

Coagulation assessment with thromboelastography during abdominal endovascular aneurysm repair in a patient with hemophilia A

Kazuki Sato et al. JA Clin Rep. .

Abstract

Background: As both APTT and APTT-based coagulation method cannot distinguish heparin effect from intrinsic coagulation factor deficiency, we implemented thromboelastography (TEG) for the coagulation assessment in a patient with hemophilia A undergoing an endovascular surgery with heparinization.

Case presentation: A 68-year-old male with hemophilia A underwent endovascular aortic repair for abdominal aortic aneurism. TEG results showed recovery of coagulation time (R) in both kaolin assay (CK) and kaolin-heparinase assay (CKH) after factor VIII replacement before heparinization. Against our expectations, R-CKH was slightly prolonged (9.0 min) during heparinization. After the administration of protamine sulfate, R in both assays showed similar values within the normal ranges.

Conclusions: The combination of CK and CKH assays could be useful to estimate factor VIII (FVIII) level when heparin concentration is low or without heparin; however, caution should be necessary for estimation of FVIII level by TEG under the effect of medium- or high-dose heparin.

Keywords: Abdominal aortic aneurysm; Endovascular aortic repair; Factor VIII; Hemophilia A; Heparin; Heparinase; Thromboelastography; Viscoelastic.

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Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Anesthesia course and coagulation monitoring. TEG was performed at 4 points. ACT was performed simultaneously with TEG and 1 more point during heparinization. ACT, activated clotting time; FVIII, factor VIII; TEG, thromboelastography
Fig. 2
Fig. 2
TEG waveforms and numerical values of TEG parameters. a TEG data before administration of FVIII concentrate. The R values for both CK and CKH were prolonged, owing to FVIII deficiency. b TEG data after FVIII replacement. The R values for both CK and CKH became normal. c TEG data after heparin administration. The R value for CK was significantly prolonged, owing to the effect of heparin, although that for CKH was also prolonged by 0.7 min. d TEG data after protamine administration. The R values for both CK and CKH were normal. All TEG parameters showed normal values, indicating adequate heparin reversal and preserved levels of coagulation factors including FVIII. Reference ranges for each parameter are indicated within brackets. FVIII, factor VIII; MA, maximum amplitude; R, reaction time; TEG, thromboelastography; NA, not applicable
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