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, yet data to guide 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. Primary outcomes were the 30-day risks of arterial thromboembolism (ATE), venous thromboembolism (VTE), and major bleeding; secondary outcomes included clinically relevant non-major bleeding (CRNMB), microvascular APS manifestations, and catastrophic APS (CAPS). Among 172 patients undergoing 282 interruptions, most (84.9%) received warfarin, and 25% were triple-positive (anti-cardiolipin, 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 (OR 7.6; 95%CI 3.2-18.2) and in those with prior ATE (OR 3.4; 95%CI 1.5-7.8). The 30-day risk of ATE was 0.7% (95%CI 0.2-2.6). Major bleeding occurred in 0.7% (95%CI 0.2-2.6), 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). A single case of probable CAPS occurred in a triple-positive patient receiving postoperative prophylactic LMWH. Guideline-directed perioperative anticoagulation management tailored to individual thrombotic and procedural bleeding risks appears feasible and safe. Our findings support individualized, risk-adapted perioperative anticoagulation management in APS.