Roberge Guillaume, Côté Benoit, Calabrino Anthony, Gilbert Nathalie, Gagnon Nathalie
Centre d'Excellence Des Maladies Vasculaires, Centre Hospitalier Universitaire de Québec, Hôpital Saint-François d'Assise, Université Laval, Québec, Canada.
Department of General Internal Medicine, Centre Hospitalier Universitaire de Québec, Hôpital de L'Enfant-Jésus, Université Laval, Québec, Canada.
Thromb J. 2022 Jul 4;20(1):38. doi: 10.1186/s12959-022-00398-8.
ChAdOx1 nCoV-19 (AstraZeneca) and Ad26COV2.S (Johnson & Johnson/Janssen) adenoviral vector vaccines have been associated with vaccine-induced immune thrombotic thrombocytopenia (VITT). Arterial thrombosis and acute limb ischemia have been described in a minority of patients with VITT. These patients usually need a revascularization, but they potentially are at a higher risk of complications. Optimal perioperative care of patients undergoing vascular surgery in acute VITT is unknown and important considerations in such context need to be described.
We report 2 cases of VITT presenting with acute limb ischemia who needed vascular surgery and we describe the multidisciplinary team decisions for specific treatment surrounding the interventions. Both patients' platelet counts initially increased after either intravenous immune globulin (IVIG) or therapeutic plasma exchange (TPE). None received platelet transfusion. They both received argatroban as an alternative to heparin for their surgery. Despite persistent positivity of anti-platelet factor 4 (PF4) antibodies and serotonin-release assay with added PF4 (PF4-SRA) in both patients, only one received a repeated dose of IVIG before the intervention. Per- and post-operative courses were both unremarkable.
In spite of persistent anti-PF4 and PF4-SRA positivity in the setting of VITT, after platelet count improvement using either IVIG or TPE, vascular interventions using argatroban can show favorable courses. Use of repeated IVIG or TPE before such interventions still needs to be defined.
ChAdOx1 nCoV-19（阿斯利康）和Ad26COV2.S（强生/杨森）腺病毒载体疫苗与疫苗诱导的免疫性血栓性血小板减少症（VITT）有关。少数VITT患者出现了动脉血栓形成和急性肢体缺血。这些患者通常需要进行血管重建，但他们可能面临更高的并发症风险。急性VITT患者接受血管手术时的最佳围手术期护理尚不清楚，需要描述在此背景下的重要考虑因素。
我们报告了2例表现为急性肢体缺血的VITT患者，他们需要进行血管手术，并描述了围绕干预措施的多学科团队的具体治疗决策。两名患者在接受静脉注射免疫球蛋白（IVIG）或治疗性血浆置换（TPE）后，血小板计数最初均有所增加。两人均未接受血小板输注。他们在手术中均接受阿加曲班作为肝素的替代品。尽管两名患者的抗血小板因子4（PF4）抗体和添加PF4的血清素释放试验（PF4-SRA）持续呈阳性，但只有一名患者在干预前接受了重复剂量的IVIG。围手术期和术后过程均无异常。
尽管在VITT情况下抗PF4和PF4-SRA持续呈阳性，但在使用IVIG或TPE改善血小板计数后，使用阿加曲班进行血管干预可显示出良好的病程。在此类干预之前使用重复的IVIG或TPE仍需明确。
