Management of perioperative hemostasis in a severe hemophilia A patient with inhibitors on emicizumab using global hemostasis assays

Ther Adv Hematol. 2019 Jun 27:10:2040620719860025. doi: 10.1177/2040620719860025. eCollection 2019.


Background: Patients with severe hemophilia A and inhibitors are at risk of bleeding during invasive procedures. The standard of care for preventing perioperative bleeding has been replacement therapy with FVIII concentrates or for patients with high-titer inhibitors, bypassing agents. However, there is no consensus on the appropriate management of surgery in patients receiving the novel agent emicizumab. The aim of this study was to demonstrate a case of a patient on emicizumab undergoing major surgery with bypassing agents with preoperative use of the thrombin generation assay (TGA) and thromboelastography (TEG).

Methods: We report a patient with hemophilia A with inhibitors who had undergone a total knee replacement while on emicizumab combined with a bypassing agent. We utilized TEG and TGA to determine which bypassing agent to choose as well as to inform about the ideal dose.

Results: We elected to use recombinant FVIIa as a bypassing agent for the surgery based upon the TGA results.

Conclusion: The TGA can be utilized to support decision-making in patients on emicizumab undergoing major surgery to both predict efficacy and potentially minimize the risk of thrombotic events.

Keywords: bypassing agents; emicizumab; hemophilia; inhibitor; thrombin generation test; thromboelastography.

Publication types

  • Case Reports