Hemostatic variability among anemic peripheral artery disease patients using comprehensive viscoelastic testing: Hemostatic profiles in anemic PAD via TEG-PM

Enya  Wang; Adriana Araceli Rodriguez Alvarez; Isabella  Ferlini Cieri; Mounika  Boya; Shiv  Patel; Jamie  Attwood; Anahita Dua

doi:10.28982/josam.8355

Authors

Enya Wang University of Rochester School of Medicine and Dentistry, University of Rochester Medical Center, Rochester, NY https://orcid.org/0000-0002-5988-7780
Adriana Araceli Rodriguez Alvarez Massachusetts General Hospital https://orcid.org/0000-0002-5394-3323
Isabella Ferlini Cieri Massachusetts General Hospital https://orcid.org/0000-0002-6163-1055
Mounika Boya Massachusetts General Hospital https://orcid.org/0000-0002-1635-1118
Shiv Patel Massachusetts General Hospital https://orcid.org/0009-0004-1704-7726
Jamie Attwood Massachusetts General Hospital https://orcid.org/0009-0000-4725-7469
Anahita Dua Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Ma, United States https://orcid.org/0000-0001-8335-3933

DOI:

https://doi.org/10.28982/josam.8355

Keywords:

peripheral artery disease, thromboelastography, anemia, thrombosis, anticoagulants, thromboprophylaxis

Abstract

Background/Aim: Peripheral arterial disease (PAD) often requires revascularization, but postprocedural thrombotic complications can lead to adverse limb and survival outcomes. Anemia is common among older patients with PAD and may alter coagulation, yet its association with peri-revascularization hemostatic profiles remains unclear. This study evaluated whether anemia was associated with differences in coagulation profiles before and after lower extremity revascularization.

Methods: This prospective, single-center study included patients with PAD who underwent revascularization from December 2022 to December 2024. Blood samples obtained before and one month after revascularization were analyzed using thromboelastography with platelet mapping (TEG-PM). Patients were categorized as anemic or non-anemic using prespecified hemoglobin thresholds. Continuous variables were compared using the Mann-Whitney U test, and categorical variables were analyzed using Fisher’s exact test.

Results: Among 344 patients, 62.8% were anemic. Compared with non-anemic patients, anemic patients were older (70 vs. 67 years, P = 0.004), had higher prevalences of diabetes mellitus (60.3% vs. 46.0%, P = 0.013) and coronary artery disease (60.8% vs. 43.7%, P = 0.002), and had lower hemoglobin levels (10.7 (1.6) vs. 14.4 (1.3) g/dL, P < 0.001). At baseline, anemic patients had greater clot strength, including higher MA-CK (65.0 (6.7) vs. 61.3 (6.3) mm, P < 0.001) and MA-CFF (29.1 (10.7) vs. 21.4 (7.7) mm, P < 0.001), as well as higher CFF-FLEV values (515 (201) vs. 400 (145) mg/dL, P < 0.001). Differences in selected fibrin-related parameters persisted at one month. Longitudinally, non-anemic patients showed larger increases in MA-CFF (4.4 (8.4) vs. -0.2 (9.5) mm, P = 0.002) and MA-ActF (3.1 (7.4) vs. -1.6 (8.2) mm, P < 0.001). Iron-deficient anemic patients had the highest clot-strength and fibrinogen-related values at both time points.

Conclusion: Anemic patients with PAD demonstrated higher clot strength and fibrin activity on TEG-PM before and after revascularization. These findings identify anemia as a marker of a more prothrombotic viscoelastic profile and warrant further study of its role in thrombotic risk stratification.

Downloads

Download data is not yet available.

References

Criqui MH, Aboyans V. Epidemiology of peripheral artery disease. Circ Res. 2015;116(9):1509-26. doi: 10.1161/CIRCRESAHA.116.303849. DOI: https://doi.org/10.1161/CIRCRESAHA.116.303849

Song P, Rudan D, Zhu Y, Fowkes FJI, Rahimi K, Fowkes FGR, et al. Global, regional, and national prevalence and risk factors for peripheral artery disease in 2015: an updated systematic review and analysis. Lancet Glob Health. 2019;7(8):e1020-30. doi: 10.1016/S2214-109X(19)30255-4. DOI: https://doi.org/10.1016/S2214-109X(19)30255-4

Shamaki GR, Markson F, Soji-Ayoade D, Agwuegbo CC, Bamgbose MO, Tamunoinemi BM. Peripheral artery disease: a comprehensive updated review. Curr Probl Cardiol. 2022;47(11):101082. doi: 10.1016/j.cpcardiol.2021.101082. DOI: https://doi.org/10.1016/j.cpcardiol.2021.101082

Heald CL, Fowkes FGR, Murray GD, Price JF, Ankle Brachial Index Collaboration. Risk of mortality and cardiovascular disease associated with the ankle-brachial index: systematic review. Atherosclerosis. 2006;189(1):61-9. doi: 10.1016/j.atherosclerosis.2006.03.011. DOI: https://doi.org/10.1016/j.atherosclerosis.2006.03.011

Sankaran VG, Weiss MJ. Anemia: progress in molecular mechanisms and therapies. Nat Med. 2015;21(3):221-30. doi: 10.1038/nm.3814. DOI: https://doi.org/10.1038/nm.3814

Desormais I, Aboyans V, Bura A, Constans J, Cambou JP, Messas E, et al. Anemia, an independent predictive factor for amputation and mortality in patients hospitalized for peripheral artery disease. Eur J Vasc Endovasc Surg. 2014;48(2):202-7. doi: 10.1016/j.ejvs.2014.04.005. DOI: https://doi.org/10.1016/j.ejvs.2014.04.005

Majumdar M, Waller D, Poyant J, McElroy I, Lella S, Feldman ZM, et al. Variability of antiplatelet response in patients with peripheral artery disease. J Vasc Surg. 2023;77(1):208-15.e3. doi: 10.1016/j.jvs.2022.08.015. DOI: https://doi.org/10.1016/j.jvs.2022.08.015

Lanser L, Fuchs D, Scharnagl H, Grammer T, Kleber ME, März W, et al. Anemia of chronic disease in patients with cardiovascular disease. Front Cardiovasc Med. 2021;8:666638. doi: 10.3389/fcvm.2021.666638. DOI: https://doi.org/10.3389/fcvm.2021.666638

Michalak SS, Wolny-Rokicka E, Nowakowska E, Michalak M, Gil L. Clinical implications of the coexistence of anemia and diabetes mellitus in the elderly population. J Diabetes Res. 2021;2021:8745968. doi: 10.1155/2021/8745968. DOI: https://doi.org/10.1155/2021/8745968

Gandhi SJ, Hagans I, Nathan K, Hunter K, Roy S. Prevalence, comorbidity and investigation of anemia in the primary care office. J Clin Med Res. 2017;9(12):970-80. doi: 10.14740/jocmr3221w. DOI: https://doi.org/10.14740/jocmr3221w

Michalak SS, Rupa-Matysek J, Gil L. Comorbidities, repeated hospitalizations, and age ≥80 years as indicators of anemia development in the older population. Ann Hematol. 2018;97(8):1337-47. doi: 10.1007/s00277-018-3321-x. DOI: https://doi.org/10.1007/s00277-018-3321-x

Hartmann J, Mason D, Achneck H. Thromboelastography (TEG) point-of-care diagnostic for hemostasis management. Point Care. 2018;17(1):15-22. doi: 10.1097/POC.0000000000000156. DOI: https://doi.org/10.1097/POC.0000000000000156

Stohlawetz PJ, Dzirlo L, Hergovich N, Lackner E, Mensik C, Eichler HG, et al. Effects of erythropoietin on platelet reactivity and thrombopoiesis in humans. Blood. 2000;95(9):2983-9. doi: 10.1182/blood.V95.9.2983.009k27_2983_2989. DOI: https://doi.org/10.1182/blood.V95.9.2983.009k27_2983_2989

Scharbert G, Wetzel L, Berlinger L, Kozek-Langenecker S. Effect of anemia on coagulation and platelet function: a whole blood in vitro study. Crit Care. 2011;15(Suppl 1):P445. doi: 10.1186/cc9865. DOI: https://doi.org/10.1186/cc9865

Antwi-Baffour S, Kyeremeh R, Annison L. Severity of anaemia has corresponding effects on coagulation parameters of sickle cell disease patients. Diseases. 2019;7(4):59. doi: 10.3390/diseases7040059. DOI: https://doi.org/10.3390/diseases7040059