Severe factor XI (FXI) deficiency is an injury related bleeding tendency. Fresh frozen plasma (FFP) or FXI concentrate are usually used for achieving hemostasis in such patients undergoing surgery but this can lead to inhibitor formation in 33% of patients with FXI level <1 U/dL (

Blood 101:4783, 2002
). Based on observations in a limited number of patients with severe FXI deficiency, we previously suggested that surgery at tissues with known fibrinolytic activity is accompanied by bleeding more frequently than in other sites (
NEJM 325:153, 1991
). In this study we retrospectively assessed the frequency of post surgical bleeding in 165 unrelated patients with severe FXI deficiency who were not treated by hemostatic means. Criteria for bleeding included local hematoma, need for surgical arrest of bleeding, or use of blood components. Bleeding occurred in 7/57 (12.3%) patients operated at tisues with low fibrinolytic activity, and in 29/48 (60.4%) patients operated at fibrinolytic sites (Table). Bleeding following circumcision (a non-fibrinolytic site) was accompanied by bleeding only in 1/64 (1.6%) and following oral surgery in 55/110 patients (50%). The relatively low frequency of bleeding following surgery at non-fibrinolytic sites advocates on demand rather than prophylactic replacement therapy when such surgery is performed.

SITE OF SURGERYNBLEEDERS% BLEEDERS
Non-fibrinolytic    
Appendicectomy 22 1 1.6 
Gastric 3 0 0 
Cholecystectomy 5 1 20 
Herniotomy 13 3 23 
Hysterectomy 5 2 40 
Orthopedic 9 0 0 
Fibrinolytic    
Tonsillectomy 33 20 60.6 
Nose 12 7 58.3 
Prostatectomy 3 2 66.6 
Circumcision    
 64 1 1.6 
Oral    
Tooth extractions 100 49 49 
Gum 10 6 60 
SITE OF SURGERYNBLEEDERS% BLEEDERS
Non-fibrinolytic    
Appendicectomy 22 1 1.6 
Gastric 3 0 0 
Cholecystectomy 5 1 20 
Herniotomy 13 3 23 
Hysterectomy 5 2 40 
Orthopedic 9 0 0 
Fibrinolytic    
Tonsillectomy 33 20 60.6 
Nose 12 7 58.3 
Prostatectomy 3 2 66.6 
Circumcision    
 64 1 1.6 
Oral    
Tooth extractions 100 49 49 
Gum 10 6 60 
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Topics:
factor xi deficiency, fibrinolytic agents, hemorrhage, surgical procedures, operative, thrombolytic therapy, plasma, fresh-frozen plasma, male circumcision, appendectomy, bleeding diathesis

Author notes

Corresponding author

2005, The American Society of Hematology
2005
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