C H A P T E R 122 
OVERVIEW OF HEMOSTASIS AND THROMBOSIS
Hemostasis preserves vascular integrity by balancing the physiologic
processes that maintain blood in a fluid state under normal circum-
stances and prevent excessive bleeding after vascular injury. Preserva-
tion of blood fluidity depends on an intact vascular endothelium and
a complex series of regulatory pathways that maintain platelets in a
quiescent state and keep the coagulation system in check. In contrast,
arrest of bleeding requires rapid formation of hemostatic plugs at
sites of vascular injury to prevent exsanguination. Perturbation of
hemostasis can lead to bleeding or thrombosis. Bleeding will occur
if there is failure to seal vascular leaks either because of defective
hemostatic plug formation or because of premature breakdown of
the plugs. In contrast, thrombosis may occur if prothrombotic stimuli
are unregulated.
Thrombosis can occur in arteries or veins and is a major cause of
morbidity and mortality. Arterial thrombosis is the most common
cause of acute coronary syndromes, ischemic stroke, and limb gan-
grene, whereas thrombosis in the deep veins of the leg leads to
postthrombotic syndrome and pulmonary embolism, which can be
fatal.
Most arterial thrombi form on top of disrupted atherosclerotic
plaques, because plaque rupture exposes thrombogenic material in
the plaque core to the blood.1 This material then triggers platelet
aggregation and fibrin formation, which results in the generation of
a platelet-rich thrombus that temporarily or permanently occludes
blood flow. Temporary occlusion of blood flow in coronary arteries
may trigger unstable angina, whereas persistent obstruction causes
myocardial infarction. The same processes can occur in the cerebral
circulation, where temporary arterial occlusion may manifest as a
transient ischemic attack, and persistent occlusion can lead to a
stroke. Likewise, critical limb ischemia can occur if there is superim-
posed thrombosis on ruptured atherosclerotic plaques in the major
arteries supplying blood to the lower extremities.
In contrast to arterial thrombi, venous thrombi rarely form at sites
of obvious vascular disruption. Although they can develop after surgi-
cal trauma to veins, or secondary to indwelling venous catheters, they
usually originate in the valve cusps of the deep veins of the calf or in
the muscular sinuses, where there is stasis.2 Sluggish blood flow in
these veins reduces the oxygen supply to the avascular valve cusps.
Hypoxemia induces endothelial cells lining the valve cusps to become
activated and express adhesion molecules onto their surfaces. Tissue
factor–bearing leukocytes and microparticles adhere to these activated
cells and induce coagulation. Impaired blood flow exacerbates local
thrombus formation by reducing clearance of activated clotting
factors. These responses constitute the three axes of the Virchow triad
associated with development of thrombosis: stasis, hypercoagulability
of the blood, and activation or disruption of the endothelium. Calf
vein thrombi that extend into the proximal veins of the leg can dis-
lodge and travel to the lungs to produce pulmonary embolism.3
Arterial and venous thrombi contain platelets and fibrin, but the
proportions differ. Arterial thrombi are rich in platelets because of
the high shear on this side of the circulatory system. In contrast,
venous thrombi, which form under low shear conditions, contain
relatively few platelets and consist mostly of fibrin and trapped red
blood cells. Because of the predominance of platelets, arterial thrombi
appear white, whereas venous thrombi appear red.
The antithrombotic drugs used for prevention and treatment of
thrombosis target components of thrombi and include antiplatelet
drugs, which inhibit platelets; anticoagulants, which attenuate
James C. Fredenburgh and Jeffrey I. Weitz
coagulation; and fibrinolytic agents that induce fibrin degradation
(see Chapter 149). With the predominance of platelets in arterial
thrombi, strategies to inhibit or treat arterial thrombosis focus mainly
on antiplatelet agents, although in the acute setting, strategies often
include anticoagulants and fibrinolytic agents. When arterial thrombi
are occlusive and rapid restoration of blood flow is imperative,
mechanical and pharmacologic methods enable thrombus extraction,
compression, or degradation. Although rarely used for this indication,
anticoagulants can also prevent recurrent ischemic events after acute
myocardial infarction. Anticoagulants are the mainstay for prevention
and treatment of venous thromboembolism because fibrin is the
predominant component of venous thrombi (see Chapter 142).
Antiplatelet drugs are less effective than anticoagulants because of the
limited platelet content of venous thrombi. Selected patients with
venous thromboembolism benefit from fibrinolytic therapy—for
example, patients with massive or submassive pulmonary embolism
achieve more rapid restoration of pulmonary blood flow with systemic
or catheter-directed fibrinolytic therapy than with anticoagulant
therapy alone. Certain patients with extensive deep vein thrombosis
in the iliac and/or femoral veins may also have a better outcome with
catheter-directed fibrinolytic therapy and/or mechanical thrombus
extraction in addition to anticoagulants (see Chapter 143).
This chapter provides an overview of hemostasis and thrombosis
by highlighting the processes involved in platelet activation and
aggregation, blood coagulation, and fibrinolysis.
HEMOSTATIC SYSTEM
The major components of the hemostatic system are the vascular
endothelium, platelets, and the coagulation and fibrinolytic systems.
Vascular Endothelium
A monolayer of endothelial cells lines the intimal surface of the cir-
culatory tree and separates the blood from the prothrombotic suben-
dothelial components of the vessel wall (see Chapter 123). As such,
the vascular endothelium encompasses about 1013 cells and covers a
vast surface area. Rather than serving as a static barrier, the healthy
vascular endothelium is a dynamic organ (Fig. 122.1) that actively
regulates hemostasis by inhibiting platelets, suppressing coagulation,
promoting fibrinolysis, and modulating vascular tone and permeabil-
ity.4 Defective vascular function can lead to bleeding if the endothe-
lium becomes more permeable to blood cells, if vasoconstriction does
not occur, or if premature degradation of hemostatic plugs reopens
repaired vasculature.
Platelet Inhibition
Endothelial cells synthesize prostacyclin and nitric oxide and release
them into the blood.4 These agents not only serve as potent vasodila-
tors but also inhibit platelet activation and subsequent aggregation
by stimulating adenylate cyclase and increasing intracellular levels
of cyclic adenosine monophospahte (cAMP). In addition, endothe-
lial cells express CD39 on their surfaces, a membrane-associated
ecto-adenosine diphosphatase (ADPase). By degrading adenosine
1831
 1832 Part XII  Hemostasis and Thrombosis

Antiplatelet Anticoagulant Profibrinolytic

Heparan
NO CD39 Prostacyclin sulfate TM EPCR TFPI t-PA u-PA

Endothelium

Fig. 122.1  THE ANTITHROMBOTIC FUNCTIONS OF THE ENDOTHELIUM. The healthy endo-
thelium has (a) antiplatelet activity because of synthesis and release of prostacyclin and nitric oxide (NO) and
expression of CD39, a membrane-associated ectoADPase; (b) anticoagulant activity because of heparan sulfate
proteoglycan-mediated activation of antithrombin and expression of thrombomodulin (TM) and endothelial
protein C receptor (EPCR), which are involved in protein C activation, and surface-bound tissue factor
pathway inhibitor (TFPI); and (c) profibrinolytic activity because of release of tissue and urokinase-type
plasminogen activator (t-PA and u-PA, respectively).

diphosphate (ADP), which is a platelet agonist, CD39 attenuates
platelet activation.
Anticoagulant Activity
Intact endothelial cells play an essential part in the regulation of
thrombin generation through a variety of mechanisms. Endothelial
cells produce heparan sulfate proteoglycans, which bind circulating
antithrombin and accelerate the rate at which it inhibits thrombin
and other coagulation enzymes. Tissue factor pathway inhibi-
tor (TFPI), a naturally occurring inhibitor of coagulation, binds
heparan sulfate on the endothelial cell surface.5 Administration
of heparin or low-molecular-weight heparin (LMWH) displaces
glycosaminoglycan-bound TFPI from the vascular endothelium, and
released TFPI may contribute to the antithrombotic activity of these
drugs.
Endothelial cells regulate thrombin generation by expressing
thrombomodulin and endothelial cell protein C receptor (EPCR) on
their surfaces. Thrombomodulin binds thrombin and alters this
enzyme’s substrate specificity such that it no longer acts as a proco-
agulant but becomes a potent activator of protein C (see Chapter
127). Activated protein C serves as an anticoagulant by degrading
and inactivating activated factor V and factor VIII (factor Va and
VIIIa, respectively), key cofactors involved in thrombin generation.
Protein S acts as a cofactor in this reaction, and EPCR enhances this
pathway by binding protein C and presenting it to the thrombin–
thrombomodulin complex for activation. In addition to its role as an
anticoagulant, activated protein C also regulates inflammation and
preserves the barrier function of the endothelium.6
Fibrinolytic Activity
The vascular endothelium promotes fibrinolysis by synthesizing and
releasing tissue-type and urokinase-type plasminogen activator (t-PA
and u-PA, respectively), which initiate fibrinolysis by converting
plasminogen to plasmin (see Chapter 126). Endothelial cells in most
vascular beds synthesize t-PA constitutively and release it in response
to stimuli such as thrombin or bradykinin. In contrast, perturbed
endothelial cells produce u-PA in the settings of inflammation and
wound repair.
Endothelial cells also produce type 1 plasminogen activator
inhibitor (PAI-1), the major regulator of both t-PA and u-PA. There-
fore net fibrinolytic activity depends on the dynamic balance between
the release of plasminogen activators and PAI-1. Fibrinolysis localizes
to the endothelial cell surface because these cells express annexin II,
a coreceptor for plasminogen and t-PA that promotes their interac-
tion. Therefore healthy vessels actively resist thrombosis and help
maintain platelets in a quiescent state.
Vascular Tone and Permeability
In addition to synthesizing potent vasodilators, such as prostacyclin
and nitric oxide, endothelial cells also produce a group of counter-
regulatory peptides known as endothelins that induce vasoconstric-
tion. Endothelial cell permeability is influenced by the connections
that join endothelial cells to their neighbors. Macromolecules traverse
the endothelium via patent intercellular junctions, by endocytosis, or
through transendothelial pores. Vasodilatation, severe thrombocyto-
penia, and high doses of heparin can increase endothelial permeability,
which may contribute to bleeding. Activated protein C may also
contribute to the barrier function of the endothelium.
Platelets
Platelets are anucleate cellular particles released into the circulation
after programmed fragmentation of bone marrow megakaryocytes
(see Chapter 124). Because they are anucleate, platelets have limited
capacity to synthesize proteins. Consequently, platelet protein
composition is determined by the parent cell as well as by those
factors endocytosed from the circulation. Thrombopoietin, a glyco-
protein synthesized in the liver and kidneys, regulates megakaryo-
cytic proliferation and maturation as well as platelet production.
Once they enter the circulation, platelets have a life span of 7 to
10 days.
Damage to the intimal lining of the vessel exposes the underlying
subendothelial matrix. Platelets home to sites of vascular disruption
and adhere to the exposed matrix proteins (see Chapter 125). Adher-
ent platelets undergo activation and not only release substances that
recruit additional platelets to the site of injury, but also promote
thrombin generation and subsequent fibrin formation (Fig. 122.2).
A potent platelet agonist, thrombin amplifies platelet recruitment and
activation. Activated platelets then aggregate to form a plug that seals
the leak in the vasculature.7 An understanding of the steps in these
highly integrated processes helps pinpoint the sites of action of
antiplatelet drugs and rationalizes the utility of anticoagulants for the
treatment of arterial thrombosis and venous thrombosis.
Adhesion
Platelets adhere to exposed von Willebrand factor (vWF) and colla-
gen, originating from endothelial cells and the subendothelium,
respectively. The platelet monolayer promotes thrombin generation
and subsequent fibrin formation. These events depend on constitu-
tively expressed receptors on the platelet surface, α2β1 and glycopro-
tein (GP) VI, which bind collagen, and GPIbα and GPIIb/IIIa
(αIIbβ3), which bind vWF. The platelet surface is crowded with recep-
tors, but those involved in adhesion are the most abundant: every
 Chapter 122  Overview of Hemostasis and Thrombosis 1833

Fig. 122.2  SITES OF ACTION OF ANTIPLATELET DRUGS. Aspirin inhibits thromboxane A2 (TXA2)
synthesis by irreversibly acetylating cyclooxygenase-1 (COX-1). Reduced TXA2 release attenuates platelet
activation and recruitment to the site of vascular injury. Ticlopidine, clopidogrel, and prasugrel irreversibly
block P2Y12, a key ADP receptor on the platelet surface; whereas ticagrelor is a reversible inhibitor of P2Y12.
Abciximab, eptifibatide, and tirofiban inhibit the final common pathway of platelet aggregation by blocking
fibrinogen and von Willebrand factor (vWF) binding to activated glycoprotein (GP) IIb/IIIa. Vorapaxar
inhibits thrombin-mediated platelet activation by targeting protease activated receptor-1 (PAR-1), the major
thrombin receptor on platelets.
 1834 Part XII  Hemostasis and Thrombosis

IIa
IIa

LDPR
IIa
RSFLLR
LDP
RLLFS

C C
C C

Response
Fig. 122.3  ACTIVATION OF PROTEASE-ACTIVATED RECEPTOR (PAR)-1 BY THROMBIN.
Thrombin (IIa) binds to the amino terminus of the extracellular domain of PAR-1 where it cleaves a specific
peptide bond. Cleavage of this bond generates a new amino-terminal sequence of Ser-Phe-Leu-Leu-Arg
(SFLLR) that acts as a tethered ligand and binds to the body of the receptor, thereby activating it. Thrombin
then dissociates from the receptor. Analogues of the first five or six amino acids of the tethered ligand sequences,
known as thrombin receptor agonist peptides, can independently activate PAR-1.

Although TP and the various ADP receptors signal through dif-
ferent pathways, they all trigger an increase in the intracellular
calcium concentration in platelets. This in turn induces shape change
via cytoskeletal rearrangement, granule mobilization and release, and
subsequent platelet aggregation. Activated platelets promote coagula-
tion by cycling phosphatidylserine from the inner membrane bilayer
to the outer layer. Surface exposure of this anionic phospholipid is
essential for assembly of coagulation factor complexes (see Chapter
126). Once assembled, these clotting factor complexes trigger a burst
of thrombin generation and subsequent fibrin formation. In addition
to converting fibrinogen to fibrin, thrombin amplifies platelet recruit-
ment and activation, thus promoting expansion of the platelet plug.
Thrombin binds to protease-activated receptors types 1 and 4 (PAR1
and PAR4, respectively) on the platelet surface and cleaves their
extended amino-termini, thereby generating new amino-termini that
serve as tethered ligands that bind internally and activate the receptors
(Fig. 122.3). Whereas low concentrations of thrombin cleave PAR1,
PAR4 cleavage requires higher thrombin concentrations.10 Cleavage
of either receptor triggers platelet activation.
In addition to providing a surface on which clotting factors
assemble, activated platelets also promote fibrin formation and sub-
sequent stabilization by releasing factor V, factor XI, fibrinogen, and
factor XIII (see Chapter 125). Thus there is coordinated activation
of platelets and coagulation, and the fibrin network that results from
thrombin action helps anchor the platelet aggregates at the site of
injury. Activated platelets also release adhesive proteins, such as vWF,
thrombospondin, and fibronectin, which augment platelet adhesion
at sites of injury, as well as growth factors, such as platelet-derived
growth factor (PDGF) and transforming growth factor-beta (TGF-
β), which promote wound healing. Platelet aggregation is the final
step in the formation of the platelet plug.
Aggregation
GPIIb/IIIa mediates platelet-to-platelet linkages that result in the
formation of clumps of platelets. On nonactivated platelets, GPIIb/
IIIa exhibits minimal affinity for its ligands. Upon platelet activation,
GPIIb/IIIa undergoes a conformational transformation, which
reflects transmission of inside-out signals from its cytoplasmic domain
to its extracellular domain.11 This transformation enhances the affin-
ity of GPIIb/IIIa for its ligands, fibrinogen, and, under high shear
conditions, vWF (see Chapter 125). Cryptic Arg-Gly-Asp (RGD)
peptide sequences located in fibrinogen and vWF, as well as a platelet-
binding Lys-Gly-Asp (KGD) sequence in fibrinogen, mediate their
interaction with GPIIb/IIIa. When subjected to high shear, circulat-
ing vWF elongates and exposes its platelet-binding domain, which
enables its interaction with the conformationally activated GPIIb/
IIIa. Similarly, initial binding to GPIIb/IIIa leads to a conformational
change in fibrinogen that unmasks additional binding sites. Divalent
fibrinogen and multivalent vWF molecules serve as bridges and bind
adjacent platelets together. Once bound to GPIIb/IIIa, fibrinogen
and vWF induce outside–inside signals that augment platelet activa-
tion and result in the activation of additional GPIIb/IIIa receptors,
creating a positive feedback loop. Because GPIIb/IIIa acts as the final
effector in platelet aggregation, it is a logical target for potent anti-
platelet drugs (see Chapters 130 and 149). Fibrin, the ultimate
product of the coagulation system, tethers the platelet aggregates
together and anchors them to the site of injury.
Coagulation
Coagulation results in the generation of thrombin, which converts
soluble fibrinogen to fibrin. Coagulation occurs through a series of
concerted activation steps, wherein a nascent protease activates an
inactive enzyme precursor (zymogen); a process that is repeated in a
cascade-like fashion. The principal enzyme complexes are composed
of a vitamin K–dependent enzyme and a non-enzyme cofactor
assembled on anionic phospholipid membranes in a calcium-
dependent fashion (see Chapter 126). Because each enzyme complex
activates a substrate that becomes the enzyme component of the
subsequent complex, a small stimulus can produce a robust response.
Initially the small amount of thrombin generated activates
 Chapter 122  Overview of Hemostasis and Thrombosis 1835

Vascular Contact
injury activation

VIIIaH
TF VIIa
Extrinsic IX X VIIIaL IXa X Intrinsic
IXa
tenase tenase

Prothrombinase

VaH
Xa Xa
VaL II
Xa

IIa

Fibrinogen Fibrin

Fig. 122.4  COAGULATION SYSTEM. Coagulation occurs through the action of discrete enzyme com-
plexes, which are composed of a vitamin K–dependent enzyme and a non-enzyme cofactor. These complexes
assemble on anionic phospholipid membranes in a calcium-dependent fashion. Vascular injury exposes tissue
factor (TF), which binds factor VIIa to form extrinsic tenase. Extrinsic tenase activates factors IX and X. Factor
IXa binds to factor VIIIa to form intrinsic tenase, which activates factor X. The contact system also leads to
activation of factor IX in response to exposure of anionic surfaces. Factor Xa binds to factor Va to form
prothrombinase, which converts prothrombin (II) to thrombin (IIa). Thrombin then converts soluble fibrino-
gen into insoluble fibrin.

non-enzyme cofactors and platelets. The activated platelets then
provide an anionic surface on which the coagulation complexes
assemble to promote rapid thrombin generation. The three predomi-
nant enzyme complexes involved in thrombin generation are extrinsic
tenase, intrinsic tenase, and prothrombinase, named for their sub-
strates, factor X and prothrombin (Fig. 122.4).
Coagulation can be divided into three phases: initiation, propaga-
tion, and termination.12,13 These phases reflect the exquisite control
over thrombin activity necessary to effect hemostasis. The initiation
phase, which is predominantly mediated by extrinsic tenase, is
responsible for generating the initial burst of thrombin required for
platelet and coagulation factor activation. The propagation phase is
largely mediated by intrinsic tenase and is responsible for the explosive
thrombin generation necessary to sustain the coagulant response. The
termination phase, which is mediated by numerous protease inhibi-
tors, ensures that thrombin generation is localized and finite. Each
of the activation complexes exhibits similar composition, assembly,
and regulation.
Because initiation and propagation reactions require a membrane
surface for assembly of factors, cells play a key role in coagulation.
Tissue factor exposure on monocytes and extravascular cells and
platelet membrane capacitation are recognized key steps. However,
other cells also make important contributions. For example, damaged
endothelium appears to support coagulation because mice deficient
in PAR4, the major thrombin receptor on mouse platelets, still
exhibit significant thrombus formation after laser injury. Red blood
cells also bind to damaged endothelium and express procoagulant
phospholipids on their surface, thereby providing additional sites for
assembly of coagulation complexes. In addition, activated neutrophils
extrude web-like structures known as neutrophil extracellular traps
(NETs). Composed of nuclear DNA, histones, and metalloproteases,
NETs promote coagulation by binding and activating platelets, trap-
ping red blood cells, and activating the contact pathway. Thus cells
contribute to coagulation at numerous sites in the cascade.
Extrinsic Tenase
This complex forms upon exposure of tissue factor–expressing cells
to the blood.14 Tissue factor exposure occurs after atherosclerotic
plaque rupture because the core of the plaque is rich in macrophages
and other cells that express tissue factor. Denuding injury to the vessel
wall also exposes tissue factor constitutively expressed by subendothe-
lial fibroblasts and smooth muscle cells. In addition to cells in the
vessel wall, circulating monocytes and monocyte-derived micropar-
ticles (small membrane fragments) also provide a source of tissue
factor. When tissue factor–bearing monocytes or microparticles bind
to platelets or other leukocytes and their plasma membranes fuse,
 1836 Part XII  Hemostasis and Thrombosis
tissue factor transfer occurs. By binding to adhesion molecules
expressed on activated endothelial cells or to P-selectin on activated
platelets, these tissue factor–bearing cells or microparticles can initiate
or augment coagulation. This phenomenon likely explains how
venous thrombi develop in the absence of obvious vessel wall injury.
Tissue factor is an integral membrane protein that serves as a
receptor for factor VIIa. Blood contains trace amounts of factor VIIa,
which has negligible activity in the absence of tissue factor.14 Although
tissue factor is present on cell surfaces, it is proposed to exist in an
encrypted, inactive form. The decryption step is thought to occur by
a disulfide bond rearrangement catalyzed by protein-disulfide isom-
erase and exposure of phosphatidylserine on the outer membrane
surface. Factor VIIa binds tissue factor in a calcium-dependent
fashion to form the extrinsic tenase complex, which is a potent activa-
tor of factors IX and X. Once activated, factor IXa and factor Xa
serve as the enzyme components of intrinsic tenase and prothrombi-
nase, respectively. Because sufficient levels of factor Xa and thrombin
are formed in response to exposure of tissue factor, the extrinsic tenase
complex is considered the essential mediator of the initiation phase.
Intrinsic Tenase
Factor IXa binds to factor VIIIa on anionic platelet or cell surfaces
to form the intrinsic tenase complex.15 Factor VIII circulates in blood
in complex with vWF. Thrombin cleaves factor VIII and releases it
from vWF, converting it to its activated form. Activated platelets
express binding sites for factor VIIIa. Once bound, factor VIIIa binds
factor IXa in a calcium-dependent fashion to form the intrinsic tenase
complex, which then activates factor X. The loss in catalytic efficiency
of intrinsic tenase that occurs with a deficiency of factors VIII or IX
in hemophilia A and B, respectively, highlights their importance.
Absence of the membrane or factor VIIIa almost completely abolishes
enzymatic activity, and the catalytic efficiency of the complete
complex is 106-fold greater than that of factor IXa alone.15 Because
intrinsic tenase activates factor X at a rate 50- to 100-fold faster than
extrinsic tenase, it plays a critical role in the amplification of factor
Xa and subsequent thrombin generation. Thus intrinsic tenase is
crucial to the propagation phase of coagulation.
Contact Pathway
The contact pathway is so named because initial identification of its
constituents (factors XII, XI, IX, and kallikrein), required contact
with artificial agents such as ellagic acid or silica for activation. For
this reason, the contact pathway lost prominence when the physiologic
tissue factor pathway was identified. Current thinking is that tissue
factor exposure represents the sole pathway for activation of coagula-
tion and thus the contact system is unimportant for hemostasis
because patients deficient in factor XII, prekallikrein, and high-
molecular-weight kininogen do not have bleeding problems (see
Chapter 126). Although patients with severe deficiency of factor XI
can bleed after trauma or surgery, spontaneous bleeding is uncom-
mon, and the plasma level of factor XI does not reliably predict the
propensity for bleeding (see Chapter 137). The capacity of thrombin
to feedback and activate platelet-bound factor XI may help to explain
this phenomenon. It also is possible that platelet-derived factor XI
may be more important for hemostasis than circulating factor XI.
We cannot ignore the contact pathway, however, because catheters
and other blood-contacting medical devices, such as stents or
mechanical valves, likely trigger clotting through this mechanism.
Factor XII bound to charged or artificial surfaces undergoes a con-
formational change that results in its activation. Factor XIIa converts
prekallikrein to kallikrein in a reaction accelerated by high-molecular-
weight kininogen, and factor XIIa and kallikrein both feed back
to activate additional factor XII. Factor XIIa propagates coagulation
by activating factor XI and generating factor XIa, the predominant
activator of factor IX (Fig. 122.5). (See box on Emerging Role of the
Contact Pathway)
Emerging Role of the Contact Pathway
The contact pathway has emerged as an important player in thrombo-
sis. It has long been recognized that the contact pathway is dispensable
for hemostasis because of the lack of a bleeding diathesis in patients
with hereditary deficiency of factor XII, prekallikrein, or high-molecular-
weight kininogen and the mild bleeding diathesis with factor XI defi-
ciency relative to deficiencies of factor VIII or factor IX. However, until
recently, the role of the contact pathway remained elusive. The pathway
was ignored for several decades because its activators were mainly
nonphysiologic substances such as kaolin or ellagic acid, compounded
by the observation that thrombin could activate factor XI, providing a
potential physiologic bypass for the contact system as the activator of
intrinsic tenase.
The renaissance in our understanding of the important contribution
of the contact pathway to thrombus stabilization and propagation
occurred as a result of the identification of new physiologic activators,
the attenuated thrombosis after venous or arterial injury observed in
mice deficient in factor XII or XI, and the development of contact
pathway–specific inhibitors. Reports that factor XI-deficient mice were
protected from arterial injury–induced thrombosis to the same extent
as factor IX-deficient mice, but did not experience bleeding, provide a
clear demarcation between hemostasis and thrombosis. The role of the
contact pathway in thrombosis gained credibility with the observation
that mice lacking factor XII were also resistant to clot formation at sites
of vascular injury. However, the physiologic mechanism for activation
of the pathway remained unclear until studies showed that nuclear
material released from neutrophils in the form of neutrophil extra-
cellular traps, nucleic acids, and inorganic polyphosphates released
from activated platelets or microorganisms, activated coagulation in a
contact pathway–dependent fashion. With a valid association between
the contact pathway and physiologic activators, investigation into the
role of the contact pathway in thrombosis exploded.
Renewed interest in the contact pathway has spurred investigation of
factors XI and XII as targets for new antithrombotic drugs. Agents tar-
geting factors XI and XII include biological inhibitors, antibodies, small
molecule inhibitors, and aptamers. Another approach is to reduce factor
levels by inhibiting protein expression through the use of antisense
oligonucleotides (ASO). This approach has been successfully applied
to factor XI, where administration of an ASO reduced postoperative
thrombosis in patients undergoing total knee arthroplasty, without an
increase in bleeding. Similar interest in targeting the contact pathway is
directed at device-related thrombosis. Thrombosis is a major cause of
failure of blood-contacting medical devices, a problem that can lead to
life-threatening complications including pulmonary embolism, coronary
occlusion, and stroke. and activation of the contact pathway by the
artificial surface is thought to be the primary cause. Therefore the
contact pathway has emerged as an attractive target for development
of agents that reduce thrombosis with little impact on hemostasis.
In addition to its role in device-related thrombosis, the contact
pathway may also contribute to the stability of arterial and venous
thrombi.16 NETs, and DNA and RNA released from damaged cells
in atherosclerotic plaques, activate factor XII, and mice given DNA-
or RNA-degrading enzymes exhibit attenuated thrombosis at sites of
arterial injury. Polyphosphates released from activated platelets also
activate factor XII, and may provide another stimulus for contact
pathway activation. Mice deficient in factor XII or factor XI form
small unstable thrombi at sites of arterial or venous damage, suggest-
ing that factor XII and factor XI contribute to thrombogenesis (see
Chapter 137). There is mounting evidence that the same is true in
humans. Thus patients with unstable angina have increased plasma
levels of factor XIa which could reflect activation by factor XIIa,
although activation by thrombin remains a possibility. The best evi-
dence for the importance of the contact system comes from the results
of a phase II study that demonstrated that knock down of factor XI
with an antisense oligonucleotide in patients undergoing elective
knee arthroplasty reduced the risk of postoperative venous thrombo-
embolism to a greater extent than enoxaparin. Furthermore, the
thrombi that did form in patients with low levels of factor XI were
very small in size, consistent with the role of factor XI in thrombus
growth. Therefore the contact system is not only an important driver

K PK
HK HK
XII XIIa
Surface
XI XIa
IX IXa
Surface
Common
Pathway
Thrombin
Fig. 122.5  CONTACT SYSTEM. Factor XII (XII) is activated by contact
with negatively charged surfaces. XIIa converts prekallikrein (PK) to kallikrein
(K), which can feed back to activate more XII. Likewise, XIIa also can feed
back to amplify its own generation. About 75% of circulating PK is bound
to high-molecular-weight kininogen (HK), which localizes it to anionic
surfaces and promotes PK activation. XIIa propagates clotting by activating
XI, which then activates IX. The resultant IXa assembles into the intrinsic
tenase complex, which activates X to initiate the common pathway of coagu-
lation. Thrombin can feedback activate factor XI to further propagate
coagulation.
of thrombosis in blood-contacting medical devices but may also
contribute to thrombus propagation in situations where tissue factor
initiates coagulation, such as after major surgery.
Prothrombinase
Being the only physiologic producer of thrombin, the prothrombinase
complex is essential for hemostasis. Factor Xa binds to factor Va, its
activated cofactor, on anionic phospholipid membrane surfaces to
form the prothrombinase complex. Activated platelets release factor
V from their α-granules, and this platelet-derived factor V may play
a more important role in hemostasis than its plasma counterpart.17
Whereas plasma factor V requires thrombin activation to exert its
cofactor activity, the partially activated factor V released from platelets
already exhibits substantial cofactor activity. Activated platelets
express specific factor Va binding sites on their surface, and bound
factor Va serves as a receptor for factor Xa. The catalytic efficiency of
factor Xa activation of prothrombin increases by 105-fold when factor
Xa incorporates into the prothrombinase complex.13 Prothrombin
binds to the prothrombinase complex, where it undergoes conversion
to thrombin in a reaction that releases prothrombin fragment 1.2
(F1.2). Plasma levels of F1.2, therefore, provide a marker of pro-
thrombin activation. Prothrombin is the most abundant coagulation
factor, and the efficiency of activation generates high local levels of
thrombin.
Termination
Because thrombin clots fibrinogen, activates cells and platelets, and
mediates anticoagulant and antifibrinolytic processes, it is imperative
to regulate its activity and location. Thus the termination phase plays
a critical role in balancing the procoagulant forces. Two principal
Chapter 122  Overview of Hemostasis and Thrombosis 1837
inhibitors modulate coagulation: TFPI and antithrombin. TFPI,
which is located on platelets and microvascular endothelial cells,
inhibits factor VIIa in a factor Xa-dependent manner. TFPI effectively
halts tissue factor-mediated initiation of coagulation, but not before
sufficient factor Xa is generated to propagate clotting. The high levels
of thrombin produced during the amplification phase are controlled
by antithrombin. This serine protease inhibitor (serpin) also inacti-
vates other coagulation proteases, including factors VIIa, IXa, Xa, and
Xia. Although antithrombin is abundant, it exhibits only moderate
inhibitory activity, except in the presence of cell-associated glycosami-
noglycans, such as heparan sulfate. This is the biochemical basis for
use of heparin as an anticoagulant (see Chapter 149). Further regula-
tion of thrombin generation is mediated by the protein C anticoagu-
lant pathway which is catalyzed by thrombin. These processes ensure
that thrombin generation is localized and limited. Sufficient thrombin
is produced, however, to ensure that coagulation occurs.
Fibrin Formation
Thrombin converts soluble fibrinogen into insoluble fibrin. Fibrino-
gen is a dimeric molecule, each half of which is composed of three
polypeptide chains, the Aα, Bβ, and γ chains. Numerous disulfide
bonds covalently link the chains together and join the two halves of
the fibrinogen molecule (Fig. 122.6). Electron micrographic studies
of fibrinogen reveal a trinodular structure with a central E domain
flanked by two D domains. Crystal structures show symmetry of
design with the central E domain, which contains the amino termini
of the fibrinogen chains, joined to the lateral D domains by coiled-
coil regions.
Fibrinogen circulates in a soluble form. Thrombin binds to the
amino termini of the Aα and Bβ chains of fibrinogen, where it cleaves
specific peptide bonds to release fibrinopeptide A and fibrinopeptide
B and generates fibrin monomer (Fig. 122.6). Because they are
products of thrombin action on fibrinogen, plasma levels of these
fibrinopeptides provide an index of thrombin activity. Fibrinopeptide
release creates new amino termini that extend as knobs from the E
domain of one fibrin monomer and insert into preformed holes in
the D domains of other fibrin monomers. This creates long strands
known as protofibrils, consisting of fibrin monomers noncovalently
linked together in a half-staggered, overlapping fashion.18
Noncovalently linked fibrin protofibrils lack tensile strength.18
The stability of the fibrin network is enhanced by platelets and
procoagulant cells.19 Platelets not only bind fibrin via GPIIb/IIIa
and promote formation of a dense fibrin network, but they also
release factor XIII. By covalently cross-linking α and γ chains
of adjacent fibrin monomers, factor XIIIa stabilizes the fibrin in
a calcium-dependent fashion and renders it relatively resistant to
physical strain and degradation. Factor XIII circulates in blood as a
heterodimer consisting of pairs of A and B subunits. The active and
calcium binding sites on factor XIII are localized to the A subunit.
Platelets contain large amounts of factor XIII in their cytoplasm,
but platelet-derived factor XIII consists only of the A subunits (see
Chapter 125). Both plasma and platelet factor XIII are activated by
thrombin.
Hemostasis depends on the dynamic balance between the forma-
tion of fibrin and its degradation. The fibrinolytic system mediates
fibrin breakdown.
Fibrinolytic System
Fibrinolysis initiates when plasminogen activators convert plasmino-
gen to plasmin, which then degrades fibrin into soluble fragments.
Blood contains two immunologically and functionally distinct plas-
minogen activators, t-PA and u-PA. t-PA mediates intravascular fibrin
degradation, whereas u-PA binds to a specific u-PA receptor (u-PAR)
on the surface of cells, where it activates cell-bound plasminogen.
Consequently, pericellular proteolysis during cell migration and tissue
remodeling and repair are the major functions of u-PA.20
 1838 Part XII  Hemostasis and Thrombosis

COOH NH2 NH2 COOH

Aα FPA FPA Aα

Bβ FPB FPB Bβ Fibrinogen

γ γ

D domain Colied E domain Colied D domain

coil coil

D E D Fibrinogen

Thrombin FPA, FPB

D E D Fibrin monomer

D E D D E D
Fibrin polymer
E D D E D D E

Factor XIIIa

D E D D E D Cross-linked
fibrin polymer
E D D E D D E

Fig. 122.6  FIBRINOGEN STRUCTURE AND CONVERSION OF FIBRINOGEN TO FIBRIN. A

dimeric molecule, each half of fibrinogen is composed of three polypeptide chains, Aα, Bβ, and γ. Numerous
disulfide bonds (lines) covalently link the chains together and join the two halves of the fibrinogen molecule
to yield a trinodular structure with a central E domain linked via the coiled-coil regions to two lateral D
domains. To convert fibrinogen to fibrin, thrombin cleaves specific peptide bonds at the amino (NH2) termini
of the Aα and Bβ chains of fibrinogen to release fibrinopeptide A (FPA) and fibrinopeptide B (FPB), thereby
generating fibrin monomer. Fibrin monomers polymerize to generate protofibrils arranged in a half-staggered
overlapping fashion. By covalently cross-linking α and γ chains of adjacent fibrin monomers, factor XIIIa
stabilizes the fibrin network and renders it resistant to degradation.

Regulation of fibrinolysis occurs on a number of levels (see
Chapter 127). The substrate of the fibrinolytic system, fibrin, serves
a transient but essential stimulatory role that subsides as it degrades.
The serpins, PAI-1, and to a lesser extent, PAI-2, inhibit the plas-
minogen activators, whereas α2-antiplasmin inhibits plasmin.
Endothelial cells synthesize PAI-1, which inhibits both t-PA and
u-PA, whereas monocytes and the placenta synthesize PAI-2, which
specifically inhibits u-PA. Thrombin-activatable fibrinolysis inhibitor
(TAFI) also modulates fibrinolysis and provides a link between
fibrinolysis and coagulation.21 Thrombosis can occur if there is
impaired activation of the fibrinolytic system, whereas excessive
activation leads to bleeding. Therefore a review of the mechanisms
of action of t-PA, u-PA, and TAFI is worthwhile.
Mechanism of Action of Tissue-Type
Plasminogen Activator
t-PA, a serine protease, contains five discrete domains: a fibronectin-
like finger domain, an epidermal growth factor (EGF) domain, two
kringle domains, and a protease domain. Synthesized as a single-chain
polypeptide, t-PA is converted into a two-chain form by plasmin.
Single- and two-chain forms of t-PA convert plasminogen to plasmin.
Native Glu-plasminogen is a single-chain polypeptide with a Glu
residue at its amino-terminus. Plasmin cleavage near the amino-
terminus generates Lys-plasminogen, a truncated form with a Lys
residue at its new amino terminus.20 t-PA cleaves a single peptide
bond to convert single-chain Glu- or Lys-plasminogen into two-chain
plasmin, composed of a heavy chain containing five kringle domains
and a light chain containing the catalytic domain. Because its open
conformation exposes the t-PA cleavage site, Lys-plasminogen is a
better substrate than Glu-plasminogen, which assumes a circular
closed conformation that renders this bond less accessible.
t-PA has little enzymatic activity in the absence of fibrin, but its
activity increases by at least three orders of magnitude when fibrin is
present. This increase in activity reflects the capacity of fibrin to serve
as a template that binds t-PA and plasminogen and promotes their
interaction. t-PA binds to fibrin via its finger and second kringle
domains, whereas plasminogen binds fibrin via its kringle domains.
Kringle domains are triple loop-like structures that bind Lys residues
on fibrin and other proteins. As fibrin undergoes degradation, more
Lys residues are exposed, which provide additional binding sites for
t-PA and plasminogen. Consequently, degraded fibrin stimulates t-PA
activation of plasminogen more than intact fibrin.
 Chapter 122  Overview of Hemostasis and Thrombosis 1839

α2-Antiplasmin, another serpin, rapidly inhibits circulating TABLE Comparison of the Features of Disorders of Primary,
plasmin by docking to its first kringle domain and then inhibiting 122.1 Secondary, or Tertiary Hemostasis
the active site.20 Because plasmin binds to fibrin via its kringle
domains, plasmin generated on the fibrin surface resists inhibition by Features Primary Secondary Tertiary
α2-antiplasmin. This phenomenon endows fibrin-bound plasmin Components Platelets, vWF, Coagulation Fibrinolysis
with the capacity to degrade fibrin. Factor XIIIa cross-links small involved and vessel wall factors
amounts of α2-antiplasmin onto fibrin, which prevents premature
Site of Skin and Muscles, joints, Wounds and
fibrinolysis.19
bleeding mucocutaneous and deep genitourinary
Like fibrin, endothelial cells bind t-PA and plasminogen and
and soft tissues tissues tract
markedly promote activation by colocalization of enzyme and sub-
strate. Cell-surface binding is mediated by receptors such as annexin Physical Petechiae and Hematomas and Hematuria and
II, gangliosides, and α-enolase, as well as an orphan transmembrane findings ecchymoses hemarthroses menorrhagia
protein expressed with a carboxy-terminal lysine residue. Plasminogen Timing of Immediate Delayed Delayed
binds to exposed lysine residues on these receptors via its kringle bleeding
domains. Lipoprotein a, which also possesses kringle domains, Inheritance Autosomal Autosomal or Autosomal
impairs cell-based fibrinolysis by competing with plasminogen for dominant X-linked recessive
cell-surface binding. This phenomenon may explain the association recessive
between elevated lipoprotein a levels and atherosclerosis.
vWF, von Willebrand factor.

Mechanism of Action of Urokinase-Type

Plasminogen Activator
Synthesized as a single-chain polypeptide, single-chain u-PA (scu-PA)
has minimal enzymatic activity. Plasmin converts scu-PA into a two-
chain form that is enzymatically active and capable of binding u-PAR,
the u-PA receptor on cell surfaces. Further cleavage at the amino-
terminus of two-chain u-PA yields a truncated, lower-molecular-
weight form that lacks the u-PAR binding domain.
Two-chain forms of u-PA readily convert plasminogen to plasmin
in the absence or presence of fibrin.20 In contrast, scu-PA does not
activate plasminogen in the absence of fibrin, but it can activate
fibrin-bound plasminogen, because plasminogen adopts the readily
activatable open conformation. Like the higher-molecular-weight
form of two-chain u-PA, scu-PA binds to cell surface u-PAR, where
plasmin can activate it. Many tumor cells elaborate u-PA and express
u-PAR on their surface. As with fibrin and plasminogen receptors,
colocalization of the reactants greatly promotes activation. Plasmin
generated on these cancer cells endows them with the capacity for
metastasis because plasmin readily degrades components of the
extracellular matrix and activates growth factors and other degrada-
tive proteases.
Mechanism of Action of TAFI
TAFI, a procarboxypeptidase B–like molecule synthesized in the liver,
circulates in blood in a latent form where thrombin bound to throm-
bomodulin can activate it to TAFIa (see Chapters 126 and 127).
Unless bound to thrombomodulin, thrombin activates TAFI ineffi-
ciently.21 TAFIa attenuates fibrinolysis by cleaving Lys residues from
the carboxy termini of chains of degrading fibrin, thereby removing
binding sites for plasminogen, plasmin, and t-PA, attenuating activa-
tion, and promoting inhibition. TAFI links fibrinolysis to coagulation
because the thrombin–thrombomodulin complex not only activates
TAFI, which attenuates fibrinolysis, but also activates protein C,
which mutes thrombin generation.
TAFIa has a short half-life in plasma because the enzyme is
unstable.21 Genetic polymorphisms can result in synthesis of more
stable forms of TAFIa. Persistent attenuation of fibrinolysis by these
variant forms of TAFIa may render patients susceptible to thrombosis.
DISORDERS OF HEMOSTASIS OR THROMBOSIS
A physiologic host defense mechanism, hemostasis focuses on arrest
of bleeding by forming hemostatic plugs composed of platelets and
fibrin at sites of vessel injury. In contrast, thrombosis reflects a
pathologic process associated with intravascular thrombi that fill the
lumens of arteries or veins.
TABLE
Disorders of Primary Hemostasis
122.2
Components Affected Causes
Platelets Quantitative or qualitative platelet disorders
vWF Inherited or acquired deficiency or
dysfunction of vWF
Vessel wall Vasculitis or abnormalities of connective
tissue supporting the vasculature
vWF, von Willebrand factor.
Hemostatic Disorders
Bleeding can occur if there is abnormal platelet plug formation and/
or reduced thrombin generation and subsequent fibrin clot formation
at the site of vascular injury; disorders of primary and secondary
hemostasis, respectively. Bleeding also can occur if the platelet/fibrin
clot is prematurely degraded because of excessive fibrinolysis; a dis-
order of tertiary hemostasis. The features distinguishing disorders of
primary, secondary, and tertiary hemostasis are outlined in Table
122.1. Hemorrhagic disorders can be inherited or acquired, and the
clinical and laboratory evaluation of such disorders is detailed in
Chapters 128 and 129, respectively.
Disorders of Primary Hemostasis
Platelet plug formation, the first step in the arrest of bleeding at sites
of injury, requires three key components (a) an adequate number of
functional platelets, (b) vWF, the molecular glue that mediates
platelet adhesion to the damaged vessel wall even in the face of high
shear, and (c) a normal blood vessel that constricts in response to
injury (Table 122.2). Because the platelet plug provides the first line
of defense against bleeding, patients with disorders of primary
hemostasis often present with immediate bleeding after injury,
and petechiae (pinpoint hemorrhages) may be noted. In addition to
skin bleeding, mucocutaneous bleeding, which may manifest as
epistaxis, bleeding gums, or hematochezia, is common as is excessive
menstrual bleeding in women (see Chapter 128).
Disorders of primary hemostasis may be inherited or acquired.22
Thrombocytopenia or congenital or acquired disorders of platelet
function are common causes of bleeding. Thrombocytopenia can be
the result of decreased production, which can occur because of failure,
infiltration, or fibrosis of the bone marrow (see Chapters 29 and 30),
increased platelet destruction, or abnormal distribution because
of platelet pooling in the spleen (see Chapter 132). Increased
 1840 Part XII  Hemostasis and Thrombosis
destruction of platelets can occur via immune mechanisms, such as
immune thrombocytopenic purpura (ITP), alloimmune thrombocy-
topenia, posttransfusion purpura, and drug-induced thrombocytope-
nia (see Chapter 131), or nonimmune mechanisms, which include
microangiopathic disorders, such as thrombotic thrombocytopenic
purpura and hemolytic uremic syndrome (see Chapter 134), as well
as consumption because of activation of coagulation, such as occurs
with disseminated intravascular coagulation (see Chapter 139).
Platelet function disorders include disorders of platelet (a) adhesion,
such as von Willebrand disease (see Chapter 138) and Bernard-Soulier
syndrome (see Chapter 125); (b) thromboxane synthesis; (c) secretion,
such as alpha or dense granule deficiency or aspirin-like secretion
defects; (d) aggregation, such as Glanzmann thrombasthenia (see
Chapter 125); or (e) procoagulant activity (Scott syndrome) where the
platelets fail to support clotting factor complex assembly (see Chapter
126). Acquired disorders of platelet function can occur in patients
taking drugs that impair platelet function, such as aspirin or nonste-
roidal antiinflammatory drugs, or in patients with uremia, paraproteins
or myelodysplastic or myeloproliferative disorders (see Chapter 130).
Bleeding can also occur with inflammation or malformations of
the blood vessels or abnormalities of the connective tissue supporting
the blood vessels. Inflammatory disorders include Henoch-Schonlein
purpura (see Chapter 152) and the vasculitis that occurs with para-
proteins or cryoglobulins or in patients with systemic lupus erythe-
matosis or other immune disorders.23 Hereditary hemorrhagic
telangiectasia is an inherited disorder associated with malformations
of the capillaries. Telangiectatic vessels can often be seen in the oral
and nasal cavities of patients with this disorder and bleeding episodes,
primarily from the nose and gastrointestinal tract, are common.
Abnormalities of the connective tissue matrix supporting the blood
vessels include Marfan syndrome, Ehlers-Danlos syndrome, and
pseudoxanthoma elasticum.24 Patients with these disorders frequently
report easy bruising.
Disorders of Secondary Hemostasis
Secondary hemostasis depends on rapid generation of sufficient
amounts of thrombin to generate a fibrin mesh that not only con-
solidates the platelet aggregates that form at sites of vascular injury,
but also is stable enough to provide a barrier that prevents leakage of
blood from the damaged blood vessel.19 Secondary hemostasis can be
compromised by (a) impaired thrombin generation because of con-
genital or acquired deficiencies of coagulation factors or cofactors or
intake of drugs that inhibit one or more steps in the coagulation
pathways, (b) congenital or acquired fibrinogen deficiency or dys-
function, and/or (c) impaired cross-linking of fibrinogen because of
congenital or acquired deficiency of factor XIII (Table 122.3).
Examples of inherited deficiencies of coagulation factors include
hemophilia A and B, deficiencies of factor VIII and factor IX, respec-
tively (see Chapter 135). Because of redundancy in the coagulation
system, only patients with a factor VIII or factor IX level less than
1% have severe disease characterized by spontaneous bleeding or
TABLE
Disorders of Secondary Hemostasis
122.3
Components Affected Causes
Coagulation factors Congenital deficiency, autoantibodies,
increased consumption, or drugs that
attenuate thrombin generation or thrombin
activity
Fibrinogen Decreased production; increased consumption
or synthesis of an abnormal protein
Impaired fibrin polymerization because of
fibrin(ogen) degradation products or
paraproteins
Fibrin cross-linking Congenital or acquired factor XIII deficiency
bleeding with minimal trauma. Those with factor levels between 1%
and 5% have an intermediate phenotype, whereas patients with factor
VIII or IX levels above 5% usually have mild disease and bleed only
with trauma or surgery. The frequency of bleeding episodes in patients
with severe hemophilia can be reduced with prophylactic administra-
tion of the appropriate factor concentrate; such treatment is also
administered to hemophiliacs with overt bleeding, or in preparation
for surgery or other major interventions. Long-lasting factor VIII and
IX molecules have been developed to reduce the frequency of factor
replacement. The half-lives of these recombinant full-length or
truncated proteins have been prolonged by conjugating them to
hydrophilic polymers such as polyethylene glycol or by fusing them
with albumin or the Fc fragment of IgG1. Conjugation to polyethyl-
ene glycol protects the proteins from proteolytic degradation, whereas
fusion technology creates new recycling pathways that diminish
natural protein breakdown (see Chapter 136). Management of
hemophilia becomes more complicated if patients develop inhibitory
antibodies that attenuate or abolish the activity of the infused factor.
Congenital deficiencies of prothrombin (factor II), factors V, VII,
X, or XI (hemophilia C), or fibrinogen are less common causes of
bleeding (see Chapter 137). In contrast, deficiencies of components of
the contact pathway—factor XII, high-molecular-weight kininogen,
and prekallikrein—are not associated with bleeding. The clinical and
laboratory evaluation of such patients is detailed in Chapters 128 and
129, respectively, whereas their treatment is outlined in Chapter 115.
Acquired deficiencies of coagulation factors can result from
decreased synthesis due to severe liver disease, vitamin K deficiency
or intake of drugs that interfere with vitamin K metabolism, con-
sumption because of excessive activation of coagulation (e.g., dis-
seminated intravascular coagulation; see Chapter 139), or accelerated
clearance due to adsorption by paraproteins or amyloid (see Chapters
86 and 87) or to autoantibodies that shorten the half-life or attenuate
or abolish clotting factor activity.
Congenital disorders of fibrinogen include absence or low levels
of fibrinogen (afibrinogenemia and hypofibrinogenemia, respectively)
or synthesis of a dysfunctional protein (dysfibrinogenemia). Acquired
disorders of fibrinogen include decreased synthesis or production of
an abnormal fibrinogen, increased fibrinogen consumption or the
presence of inhibitors that interfere with fibrin polymerization, such
as paraproteins, autoantibodies, particularly in patients with systemic
lupus erythematosis or other immune disorders or elevated levels of
fibrin(ogen) degradation products.
Stabilization of fibrin requires cross-linking of the α and γ chains
of adjacent fibrin monomers to yield a polymer that is resistant to
premature breakdown. Factor XIIIa, a transglutaminase, performs
this function by catalyzing the condensation of lysine residues on one
chain with glutamic acid residues on another chain.25 Congenital or
acquired deficiency of factor XIII can impair cross-linking, resulting
in bleeding. The hallmarks of severe factor XIII deficiency include
umbilical stump bleeding in the neonatal period (see Chapter 150),
intracranial hemorrhage with little or no trauma, recurrent soft tissue
hemorrhages, and, in females, recurrent spontaneous miscarriages.
Disorders of Tertiary Hemostasis
Tertiary hemostasis depends on the generation of plasmin, which
degrades fibrin and restores blood flow in damaged vessels. Premature
lysis of fibrin in hemostatic plugs can lead to bleeding; this can occur
systemically or can be localized (Table 122.4). Systemic fibrinolysis
that occurs in the absence of activation of coagulation, so-called
primary hyperfibrinolysis, is rare but can occur with inherited defi-
ciency of PAI-1 or α2-antiplasmin, the inhibitors of the plasminogen
activators and plasmin, respectively, advanced liver disease, and some
snake bites. More commonly, systemic hyperfibrinolysis is secondary
to activation of coagulation by procoagulants such as tissue factor
(e.g., in patients with metastatic cancer) or artificial surfaces (e.g.,
in cardiopulmonary bypass surgery or with cardiac assist devices).
Examples of localized hyperfibrinolysis include menorrhagia or hema-
turia after prostatectomy triggered by excessive plasmin generation

TABLE
Disorders of Tertiary Hemostasis
122.4
Component Affected Causes
Plasminogen activators Increased t-PA or u-PA release in the GU
tract or other tissues
Plasmin Deficiency of PAI-1 or α2-antiplasmin,
resulting in an increased plasmin
concentration
Plasminogen activation Enhanced plasminogen activation
secondary to activation of coagulation
by procoagulants, such as cancer cells,
artificial surfaces, or snake venoms
GU, Genitourinary; PAI-1, plasminogen activator inhibitor 1; t-PA, tissue
plasminogen activator; u-PA, urokinase-type plasminogen activator.
induced by the high concentrations of t-PA and u-PA in the uterus
and genitourinary tract, respectively.
Thrombotic Disorders
Thrombosis may occur in arteries, in the chambers of the heart, or
in the veins. Factors contributing to thrombosis in these sites include
endothelial injury or activation, reduced blood flow, and hypercoagu-
lability of the blood, the so-called Virchow triad.
Arterial Thrombosis
Most arterial thrombi occur on top of disrupted atherosclerotic
plaques. Plaques with a thin fibrous cap and a lipid-rich core are most
prone to disruption. Erosion or rupture of the fibrous cap exposes
thrombogenic material in the lipid-rich core to the blood and triggers
platelet activation and thrombin generation. The extent of plaque
disruption and the content of thrombogenic material in the plaque
determine the consequences of the event, regardless of whether it
occurs in the cerebral circulation (see Chapter 145), the coronary
circulation (see Chapter 146), or the major arteries of the legs (see
Chapter 148), but host factors also contribute. Breakdown of regula-
tory mechanisms that limit platelet activation and inhibit coagulation
can augment thrombosis at sites of plaque disruption.
Decreased production of nitric oxide and prostacyclin by diseased
endothelial cells can trigger vasoconstriction and platelet activation.
Proinflammatory cytokines lower thrombomodulin expression by
endothelial cells, which promotes thrombin generation, and they
stimulate PAI-1 expression which inhibits fibrinolysis.
Products of blood coagulation contribute to atherogenesis, as well
as to its complications (see Chapter 144). Microscopic erosions in
the vessel wall trigger the formation of tiny platelet-rich thrombi.26
Activated platelets release PDGF and TGF-β, which promote a
fibrotic response. Thrombin generated at the site of injury not only
activates platelets and converts fibrinogen to fibrin, but also activates
PAR-1 on smooth muscle cells and induces their proliferation, migra-
tion, and elaboration of extracellular matrix. Incorporation of thrombi
into plaques promotes plaque growth, and decreased endothelial cell
production of heparan sulfate—which normally limits smooth muscle
proliferation—contributes to plaque expansion.26 The multiple links
between atherosclerosis and thrombosis have prompted the term
atherothrombosis (see Chapter 144).
Intracardiac Thrombosis
Thrombi can form in the left ventricle after transmural myocardial
infarction or with an aneurysm or dyskinetic ventricle, or in the
left atrial appendage, particularly in patients with atrial fibrillation
(see Chapter 147). Damage to the endothelium after myocardial
Chapter 122  Overview of Hemostasis and Thrombosis 1841
infarction and abnormal blood flow are the major triggers for left
ventricular thrombus formation. With rapid atrial fibrillation, there
also is stasis and turbulent blood flow in the left atrial appendage,
which is a long, blind-ended trabeculated pouch.27 This may lead to
localized activation of endothelial cells and subsequent loss of their
anticoagulant phenotype, a process amplified by adhesion of leuko-
cytes and subsequent elaboration of proinflammatory cytokines. The
generation of thrombin creates a local hypercoagulable state that
likely promotes thrombus formation on the abnormal endothelium.
Embolization of these thrombi to the brain is a common cause of
ischemic stroke and the major cause of mortality and morbidity in
patients with atrial fibrillation.
Venous Thrombosis
The causes of venous thrombosis include those associated with hyper-
coagulability, which can be genetic or acquired, and the mainly acquired
risk factors, such as advanced age, obesity, or cancer, which are associ-
ated with immobility (see Chapters 140 and 142). Inherited hyperco-
agulable states and these acquired risk factors combine to establish the
intrinsic risk of thrombosis for each individual.2 Superimposed trigger-
ing factors, such as surgery, pregnancy, or hormonal therapy, modify
this risk, and thrombosis occurs when the combination of genetic,
acquired, and triggering forces exceed a critical threshold.28
Some acquired or triggering factors entail a higher risk than
others. For example, major orthopedic surgery, neurosurgery, multiple
trauma, and metastatic cancer (particularly adenocarcinoma) are
associated with the highest risk; prolonged bed rest, antiphospholipid
antibodies (see Chapter 141), and the puerperium are associated with
an intermediate risk; whereas pregnancy, obesity, long-distance travel,
or the use of oral contraceptives or hormonal replacement therapy
are mild risk factors. Up to half of patients who present with venous
thromboembolism before the age of 45 have inherited hypercoagu-
lable disorders—so-called thrombophilia (see Chapter 140)—particu-
larly those whose event occurred in the absence of risk factors or with
minimal provocation, such as after minor trauma or a long-haul flight
or with estrogen use.29
TREATMENT OF DISORDERS OF HEMOSTASIS
AND THROMBOSIS
By the midpoint of the 20th century, two major anticoagulant drugs
had been discovered, characterized, and given to humans for preven-
tion or treatment of thrombotic disorders. Heparin and vitamin K
antagonists, such as warfarin, dominated treatment regimens for
decades. In the same era, determination of their mechanisms of action
and dosing was aided by the discovery of the main players of the
coagulation system, resulting from the development of sensitive
functional assays to monitor their activity. Heparin and warfarin still
represent effective members of the anticoagulant armamentarium;
however, detailed understanding of the biochemistry and cell biology
of hemostasis has directly contributed to the development of new
therapies. Heparin derivatives with more predictable pharmacokinet-
ics have improved therapy and reduced complications (see Chapter
149). Small molecule, direct inhibitors of thrombin and factor Xa have
been developed as non–vitamin K antagonist (or direct) oral antico-
agulants, such as dabigatran, rivaroxaban, apixaban, and edoxaban,
that are replacing conventional therapies (see Chapter 149). The
resurgence of interest in the contact system as a potential mediator of
thrombosis has led to the investigation of factors IX, XI, and XII as
new targets for therapy. Likewise new antiplatelet agents that antago-
nize activation or aggregation steps are being used in conjunction with
aspirin to prevent and treat arterial thrombosis (see Chapter 146). On
the hemostasis side, regimens to treat bleeding disorders include
administration of factors VIIa, VIII, or IX, and prothrombin complex
concentrates (see Chapters 135, 136, and 137). The new agents and
treatment regimens highlight the therapeutic benefit that has resulted
from our detailed understanding of hemostasis and thrombosis.
 1842 Part XII  Hemostasis and Thrombosis
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