Thrombin generation on vascular cells in the presence of factor VIII and/or emicizumab

J Thromb Haemost. 2024 Jan;22(1):112-125. doi: 10.1016/j.jtha.2023.09.017. Epub 2023 Sep 29.


Background: The effect of factor VIII (FVIII) or emicizumab on thrombin generation is usually assessed in assays using synthetic phospholipids. Here, we assessed thrombin generation at the surface of human arterial cells (aortic endothelial cells [hAECs] and aortic vascular smooth muscle cells [hVSMCs]).

Objectives: To explore the capacity of hAECs (resting or stimulated) and hVSMCs to support thrombin generation by FVIII or emicizumab.

Methods: Primary hVSMCs and hAECs were analyzed for tissue factor (TF)-activity and antigen, phosphatidylserine (PS)-exposure, tissue factor pathway inhibitor (TFPI)-content and thrombomodulin expression. Cells were incubated with FVIII-deficient plasma spiked with FVIII, emicizumab, activated prothrombin complex concentrate (APCC) or combinations thereof.

Results: TF activity and PS-exposure were present on both hVSMCs and hAECs. In contrast, thrombomodulin and TFPI were expressed on hAECs, while virtually lacking on hVSMCs, confirming the procoagulant nature of hVSMCs. Tumor necrosis factor α-mediated stimulation of hAECs increased not only TF antigen, TF activity, and PS-exposure but also TFPI and thrombomodulin expression. As expected, FVIII and emicizumab promoted thrombin generation on nonstimulated hAECs and hVSMCs, with more thrombin being generated on hVSMCs. Unexpectedly, FVIII and emicizumab increased thrombin generation to a lesser extent on stimulated hAECs compared with nonstimulated hAECs. Finally, adding emicizumab to FVIII did not further increase thrombin generation, whereas the addition of emicizumab to APCC resulted in exaggerated thrombin generation.

Conclusion: Tumor necrosis factor stimulation of hAECs increases both pro- and anticoagulant activity. Unexpectedly, the increased anticoagulant activity is sufficient to limit both FVIII- and emicizumab-induced thrombin generation. This protective effect disappears when emicizumab is combined with APCC.

Keywords: emicizumab; endothelial cells; factor VIII; smooth muscle cells; thrombin generation.

MeSH terms

  • Antibodies, Bispecific* / pharmacology
  • Anticoagulants
  • Endothelial Cells / metabolism
  • Factor IX
  • Factor VIII / metabolism
  • Factor VIIa
  • Hemophilia A*
  • Hemostatics*
  • Humans
  • Thrombin / metabolism
  • Thrombomodulin


  • Factor VIII
  • Thrombin
  • emicizumab
  • Thrombomodulin
  • Hemostatics
  • Antibodies, Bispecific
  • Factor VIIa
  • Factor IX
  • Anticoagulants