Perioperative management of antithrombotic therapy in patients with thrombotic antiphospholipid syndrome

Patients with thrombotic antiphospholipid syndrome (APS) frequently require interruption of anticoagulation for invasive procedures; however, data to guide the perioperative management remain limited. We conducted a single-center, retrospective cohort study of adults with thrombotic APS who underwent planned periprocedural interruption of anticoagulation between 2016 and 2025. The primary outcomes were the 30-day risks for arterial thromboembolism (ATE), venous thromboembolism, and major bleeding; secondary outcomes included clinically relevant nonmajor bleeding (CRNMB), microvascular APS manifestations, and catastrophic APS (CAPS). Among 172 patients who underwent 282 interruptions, most (84.9%) received warfarin and 25% were triple-positive (anticardiolipin, anti-β2-glycoprotein I, and lupus anticoagulant). Bridging with low-molecular-weight heparin (LMWH) was used in 84.7% of warfarin interruptions. Therapeutic-dose bridging was more frequently used in patients with triple-positive APS (odds ratio [OR], 7.6; 95% confidence interval [CI], 3.2-18.2) and in those with a previous ATE (OR, 3.4; 95% CI, 1.5-7.8). The 30-day risk for ATE was 0.7% (95% CI, 0.2-2.6). Major bleeding occurred in 0.7% (95% CI, 0.2-2.6) of patients with both events following high bleed-risk procedures. One bleeding event was fatal, corresponding to a mortality risk of 0.4% (95% CI, 0.1-2.0). CRNMB occurred in 3.2% (95% CI, 1.7-6.0) of patients. A single case of probable CAPS occurred in a triple-positive patient who received postoperative prophylactic LMWH. Guideline-directed perioperative anticoagulation management tailored to individual thrombotic and procedural bleeding risks seems feasible and safe. Our findings support individualized, risk-adapted perioperative anticoagulation management in APS.