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Case Reports
. 2023;16(4):273-276.
doi: 10.3400/avd.avd.cr.23-00060. Epub 2023 Oct 11.

Intraoperative Heparin Resistance after Administration of Andexanet Alfa to Manage an Internal Iliac Artery Aneurysm Rupture: A Case Report

Kanetsugu Nagao  1 , Shigeyuki Yamashita  1 , Rina Ebe  1 , Norihito Naruto  2 , Hisakatsu Ito  3 , Saori Nagura  1 , Toshio Doi  1 , Kazuaki Fukahara  1 , Naoki Yoshimura  1
Affiliations
Case Reports

Intraoperative Heparin Resistance after Administration of Andexanet Alfa to Manage an Internal Iliac Artery Aneurysm Rupture: A Case Report

Kanetsugu Nagao et al. Ann Vasc Dis. 2023.

Abstract

Antithrombotic agents are increasingly prescribed to older adults; however, they are associated with bleeding-related complications. We describe a case of intraoperative heparin resistance after administration of andexanet alfa (AA). An 81-year-old man was diagnosed with a ruptured internal iliac artery aneurysm. The patient required emergency endovascular aneurysm repair and was treated with AA because he was receiving apixaban. Despite high-dose intraoperative heparin administration, his activated coagulation time was not prolonged. Our findings suggest that AA should be administered with caution in patients experiencing potentially fatal bleeding (requiring surgical intervention) who are also receiving direct oral anticoagulants.

Keywords: andexanet alfa; endovascular aneurysm repair; heparin resistance.

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Figures

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Fig. 1 (A) Preoperative computed tomography image. (B) Intraoperative final angiographic portrait. (C) Postoperative computed tomography image (3D reconstruction). 3D: three-dimensional
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Fig. 2 Infusion of AA and heparin during surgery under general anesthesia. ACT is 149 s following infusion of 14,000 U UFH. TEG parameters following infusion of 10,000 U UFH and protamine are shown here. AA: andexanet alfa; ACT: activated coagulation time; citrated kaolin (CK); citrated kaolin with heparinase (CKH); citrated rapid TEG (CRT); citrated functional fibrinogen (CFF); UFH: unfractionated heparin; TEG: thrombelastographs; EVAR: endovascular aneurysm repair; R: reaction time; MA: maximum amplitude; ×: start/end of anesthesia; M: start of mask ventilation; T: intubation/extubation; ⦾: start/end of surgery
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