PO123 | PERIOPERATIVE MANAGEMENT OF FEMORAL FRACTURE SURGERY IN AN ELDERLY PATIENT WITH ACQUIRED HEMOPHILIA A RECEIVING EMICIZUMAB

C. Simion, E. Zanon, B. Stocco, G. Saggiorato, F. Sartorello, C. Bulato, P. Simioni | Department of Medicine, University of Padova, Italy

Background. Acquired hemophilia A (AHA) is a rare autoimmune bleeding disorder predominantly affecting elderly patients, in whom major surgery represents a particularly high-risk clinical scenario. Although emicizumab was originally developed for congenital hemophilia A, its use has progressively extended to patients with AHA, particularly in cases characterized by recurrent bleeding or difficult disease control. However, evidence guiding perioperative management in this setting remains extremely limited, and specific recommendations for patients with AHA receiving emicizumab prophylaxis are lacking.
Case report. We report the case of an 80 years old woman with AHA complicated by a high-titer factor VIII inhibitor and marked clinical frailty. The disease course was characterized by recurrent bleeding episodes and fluctuating factor VIII levels despite immunosuppressive therapy with corticosteroids and cyclophosphamide. Following a severe relapse, emicizumab prophylaxis was initiated, leading to clinical stabilization. In September 2025, the patient sustained a femoral fracture requiring urgent orthopedic surgery. Perioperative hemostatic management was based on continuation of emicizumab prophylaxis combined with recombinant activated factor VII (rFVIIa, eptacog alfa), administered at tapering doses over a total of seven days, together with adjunctive tranexamic acid. Surgery was successfully performed. A postoperative hemoglobin decrease required transfusion support, but the patient remained hemodynamically stable, with no major bleeding or thrombotic complications. In the postoperative period, a partial remission of acquired hemophilia A was observed, with factor VIII activity rising above 30%, allowing discontinuation of emicizumab prophylaxis (Figure 1).
Conclusions. To our knowledge, this is the first reported case of femoral fracture surgery in an elderly patient with AHA receiving emicizumab prophylaxis. This case demonstrates that major orthopedic surgery can be successfully managed in selected AHA patients under emicizumab using a structured perioperative approach with rFVIIa. The absence of specific recommendations for this setting highlights the importance of shared clinical experience and structured reporting to support decision-making in this high-risk population.