Does a patient with antiphospholipid syndrome (APS) require anticoagulation during surgery?

Perioperative Anticoagulation Management for Patients with Antiphospholipid Syndrome

Patients with antiphospholipid syndrome (APS) undergoing surgery require bridging anticoagulation therapy to prevent perioperative thrombotic events. This is especially important for those with triple-positive APS or recurrent thrombosis history, as they are at high risk for perioperative thrombotic complications.

Risk Assessment and Preoperative Management

High Thrombotic Risk Features in APS

• Triple-positive antibody profile (lupus anticoagulant, anti-cardiolipin, and anti-β2-glycoprotein-I)
• History of recurrent venous thrombosis or pulmonary embolism
• Previous arterial thrombosis
• APS secondary to systemic lupus erythematosus

Preoperative Anticoagulation Protocol

1. Stop warfarin 5 days before surgery to allow INR to decrease to ≤1.5 1
2. Start bridging therapy with therapeutic-dose LMWH 36 hours after the last warfarin dose (approximately 3 days before surgery) 1
3. Administer last preoperative LMWH dose 24 hours before surgery, using half the normal daily dose 1
4. Check INR the day before surgery - if >1.8, consider low-dose oral vitamin K (1-2.5 mg) 1

Intraoperative Considerations

• For high bleeding risk procedures (e.g., neurosurgery):
  • Consider plasmapheresis as an alternative to bridging anticoagulation 2
  • Monitor for signs of thrombosis during surgery
  • Use mechanical thromboprophylaxis (compression devices)

Postoperative Management

Low Bleeding Risk Procedures

• Resume therapeutic LMWH within 24 hours after surgery 1
• Restart warfarin the evening of surgery or the next morning at the usual maintenance dose 1
• Continue LMWH until INR reaches therapeutic range (2.0-3.0 for most APS patients) 3

High Bleeding Risk Procedures (e.g., spinal surgery, major neurosurgical procedures)

• Delay therapeutic-dose LMWH for 48-72 hours after surgery 1
• Consider starting with prophylactic-dose LMWH first, then escalating to therapeutic dose
• Use mechanical thromboprophylaxis until anticoagulation is resumed
• Monitor closely for both bleeding and thrombotic complications

Special Considerations

Target INR for APS Patients

• Standard target INR: 2.0-3.0 for most APS patients with venous thrombosis 1, 3
• Higher target INR (2.5-3.5) may be considered for patients with recurrent thrombosis despite standard anticoagulation 3

Direct Oral Anticoagulants (DOACs)

• DOACs are not recommended for APS patients, especially those who are triple-positive or have arterial thrombosis 1
• Vitamin K antagonists (warfarin) remain the preferred anticoagulant for APS patients 1

Catastrophic APS Prevention

• Monitor for early signs of catastrophic APS (multi-organ thrombosis, fever, SIRS)
• Consider prophylactic steroids in high-risk patients
• Maintain adequate hydration

Common Pitfalls to Avoid

1. Inadequate bridging therapy - Patients with APS, especially triple-positive or with SLE, may develop thrombosis rapidly when anticoagulation is interrupted 4
2. Prolonged anticoagulation interruption - Minimize time without anticoagulation coverage
3. Relying on DOACs - Evidence shows higher thrombosis rates with DOACs compared to warfarin in APS patients 1
4. Ignoring lupus anticoagulant interference - Lupus anticoagulant can affect coagulation monitoring tests, potentially giving misleading results 5
5. Delaying postoperative anticoagulation - Resume anticoagulation as soon as hemostasis is achieved to prevent thrombotic events

The perioperative management of APS patients requires careful planning and coordination between surgeons, anesthesiologists, and rheumatologists to balance the competing risks of thrombosis and bleeding. Following this protocol will help minimize the risk of perioperative thrombotic complications in this high-risk population.