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. 2024 Dec;12(6):131-137.
doi: 10.1055/a-2542-4290. Epub 2025 May 8.

Management of Direct Oral Anticoagulants in Acute Type A Aortic Dissection

Robert Semco  1 , Thais Faggion Vinholo  2 , Jake Awtry  2 , Asishana Osho  3 , Kim de la Cruz  2 , Ashraf A Sabe  2
Affiliations

Management of Direct Oral Anticoagulants in Acute Type A Aortic Dissection

Robert Semco et al. Aorta (Stamford). 2024 Dec.

Erratum in

Abstract

Background: Direct oral anticoagulants (DOACs) are a commonly used class of anti-coagulants that may complicate surgical management of acute Type A aortic dissection (ATAAD).

Methods: Surgical management and clinical courses were described for patients who presented to our institution with ATAAD while taking DOACs, after FDA approval of the two currently available reversal agents. A thorough literature review was completed for cases of administration of DOAC reversal agents in ATAAD.

Results: The only patient treated with andexanet-alfa had heparin insensitivity while on cardiopulmonary bypass. Four other patients were successfully managed with a combination of surgical delay and factor repletion.

Conclusion: This case series demonstrates that preoperative management of DOACs in patients with ATAAD may employ factor repletion with success. Literature review demonstrated a safety signal for heparin insensitivity or pump thrombosis when andexanet-alfa was administered before or while on cardiopulmonary bypass or extracorporeal membrane oxygenation. Our institutional clinical practice guidelines recommend against administration of andexanet-alfa within 4 to 6 hours before heparinization for surgery in ATAAD but recommend considering andexanet-alfa administration when there is life-threatening bleeding after heparin reversal that is thought to be due to Xa-inhibition with laboratory evidence of elevated anti-Xa activity.

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Conflict of interest statement

K.D.L.C. discloses being a nonpaid consultant and speaker for Terumo Aortic and Edwards Lifesciences. All other authors certify that there are no relationships with any financial organization regarding the material discussed in the manuscript.

Figures

Fig. 1
Fig. 1
Clinical practice flowchart for management of oral factor Xa inhibitors in patients requiring surgery.
See this image and copyright information in PMC

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