Minimally invasive coronary artery bypass grafting via a left lateral mini-thoracotomy in severe hemophilia A: a case report

Life expectancy in patients with hemophilia A has increased owing to advances in factor VIII replacement, and the prevalence of age-related comorbidities such as coronary artery disease (CAD) is rising. However, coronary revascularization in severe hemophilia A remains challenging because both antithrombotic therapy and surgery can precipitate serious bleeding. We report a case of minimally invasive coronary artery bypass grafting (MICS-CABG) in a patient with severe hemophilia A, focusing on perioperative factor VIII management. A 50-year-old man (height 167 cm, weight 81 kg) with severe hemophilia A (baseline factor VIII activity < 1%) was followed at our institution. His bleeding history included mucosal and gastrointestinal hemorrhage requiring on-demand factor VIII replacement. He presented with exertional chest pain, and coronary angiography revealed single-vessel CAD involving the left anterior descending (LAD) and diagonal territory. Surgical revascularization was selected to avoid the need for long-term dual antiplatelet therapy after percutaneous coronary intervention involving an indwelling drug-eluting stent. Preoperative echocardiography showed preserved left ventricular function. MICS-CABG via a left lateral mini-thoracotomy was performed, with the left internal thoracic artery (LITA) used as a sequential graft to the diagonal branch and LAD. Perioperative hemostasis was managed in collaboration with the hematologists using recombinant factor VIII. A preoperative bolus was followed by continuous infusion and scheduled dose adjustments based on serial factor VIII activity measurements. Total operative time was 5 h 32 min, and intraoperative blood loss was 407 mL without transfusion. No major bleeding or thrombotic events occurred. Postoperative coronary computed tomography confirmed excellent graft patency, and the patient was discharged without complications. Even in severe hemophilia A, MICS-CABG can be performed safely when combined with meticulous perioperative factor VIII replacement and activity monitoring. A minimally invasive surgical approach may help limit blood loss and transfusion requirements, and represents a useful revascularization option for selected patients with hemophilia and CAD.