A Phenotype-driven strategy for bilateral VATS in severe factor VII deficiency: securing hemostasis without complete parameter correction.

BACKGROUND: Perioperative management for severe Factor VII (FVII) deficiency in thoracic surgery typically aims to reduce bleeding risk by correcting coagulation parameters with factor replacement—a strategy limited by cost, thrombotic risk, and availability. This report describes a phenotype-driven strategy, guided by a prior uneventful invasive procedure, that enabled safe surgery without routine factor replacement, offering a viable approach despite profound laboratory abnormalities. CASE PRESENTATION: A 58-year-old male with severe congenital FVII deficiency (FVII: C < 8%) and symptomatic bilateral giant bullae was declined surgery at multiple centers due to bleeding concerns. Critically, he had previously undergone an uneventful tube thoracostomy, demonstrating a mild bleeding phenotype despite a prothrombin time of 72.7s. A multidisciplinary team prioritized this clinical evidence over laboratory values. Bilateral VATS bullectomy was performed using only minimal, targeted cryoprecipitate, without recombinant FVIIa or normalization goals. CONCLUSION: The procedure was completed with a total blood loss of 20 mL and no complications. The patient was discharged on postoperative day seven. This case provides a validated surgical management framework for severe FVII deficiency, demonstrating that major thoracic surgery can be safely performed by prioritizing clinical phenotype and precision VATS technique over costly factor concentrates and routine coagulation normalization.