Boehnel Christian, Rickli Hans, Graf Lukas, Maeder Micha T
Cardiology Department, Kantonsspital St. Gallen, Switzerland.
Center for Laboratory Medicine, Hemostasis and Hemophilia Center, St. Gallen, Switzerland.
Catheter Cardiovasc Interv. 2018 Jul;92(1):1-15. doi: 10.1002/ccd.27255. Epub 2017 Sep 12.
We aimed to summarize the evidence for periprocedural and long-term strategies to both minimize the bleeding risk and ensure sufficient anticoagulation and antiaggregation in hemophilia patients undergoing coronary angiography with or without percutaneous coronary interventions (PCI).
Hemophilia patients undergoing coronary angiography and PCI are at risk of bleeding due to deficiency of the essential clotting factors VIII or IX combined with the need of peri-interventional anticoagulation and antiaggregation and dual antiplatelet therapy (DAPT) after PCI.
We report on a patient with moderate hemophilia B undergoing single-vessel PCI with administration of factor IX concentrate during the procedure and during the 1-month DAPT period. In addition, a systematic review of patients (n = 54, mean age 58 ± 10 years) with hemophilia A (n = 45, 83%) or B (n = 9, 17%) undergoing coronary angiography with or without PCI is presented.
Peri-interventional factor substitution was performed in the majority (42 of 54, 78%) but not all patients. In 38 of 54 (70%) patients undergoing coronary angiography, PCI with balloon dilation (n = 5), bare metal (n = 31), or drug-eluting stents (n = 2) was performed. For PCI unfractioned heparin (n = 24), low molecular weight heparin (n = 2), bivalirudin (n = 4), or no periprocedural anticoagulation at all (n = 8) were used. PCI was successful in all cases. After stenting, the majority (28 of 33; 85%) was treated with DAPT (median duration 1 month). Major periprocedural bleeding episodes occurred in 3 of 54 (6%) patients. Bleeding during follow-up occurred in 11 of 54 (20%) patients.
Coronary angiography and PCI in patients with hemophilia are effective and safe when applying individualized measures to prevent bleeding.
我们旨在总结围手术期及长期策略的证据，以尽量降低出血风险，并确保在接受或未接受经皮冠状动脉介入治疗（PCI）的血友病患者中进行充分的抗凝和抗聚集治疗。
接受冠状动脉造影和PCI的血友病患者因缺乏必需的凝血因子VIII或IX，再加上围手术期抗凝、抗聚集以及PCI术后双联抗血小板治疗（DAPT）的需求，存在出血风险。
我们报告了1例中度B型血友病患者，在手术过程及1个月的DAPT期间给予IX因子浓缩物进行单支血管PCI。此外，还对54例（平均年龄58±10岁）接受或未接受PCI的A 型血友病患者（n = 45，83%）或B型血友病患者（n = 9，17%）进行了系统评价。
大多数患者（54例中的42例，78%）但并非所有患者在围手术期进行了因子替代治疗。在54例接受冠状动脉造影的患者中，38例（70%）进行了PCI，包括球囊扩张（n = 5）、裸金属支架（n = 31）或药物洗脱支架（n = 2）置入。对于PCI，使用了普通肝素（n = 24）、低分子肝素（n = 2）、比伐卢定（n = 4）或完全不进行围手术期抗凝（n = 8）。所有病例的PCI均成功。支架置入后，大多数患者（33例中的28例；85%）接受了DAPT治疗（中位持续时间1个月）。54例患者中有3例（6%）发生了主要围手术期出血事件。随访期间，54例患者中有11例（20%）发生出血。
对血友病患者进行冠状动脉造影和PCI时，采用个体化措施预防出血是有效且安全的。
