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CC BY 4.0 · Aorta (Stamford)
DOI: 10.1055/a-2542-4290
Original Research Article

Management of Direct Oral Anticoagulants in Acute Type A Aortic Dissection

Robert Semco 
1   Harvard Medical School, Boston, Massachusetts
,
Thais Faggion Vinholo
2   Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
,
Jake Awtry
2   Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
,
Asishana Osho
3   Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
,
Kim de la Cruz
2   Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
,
Ashraf A. Sabe 
2   Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
› Author Affiliations Funding None.
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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.

Keywords

direct-acting oral anticoagulants - aortic dissection - anticoagulation reversal

Authors' Contribution

All authors have given substantial contributions to the conception and design of the manuscript as well as the interpretation of the data. Robert Semco performed data acquisition and Robert Semco, Thais Faggion Vinholo, and Jake Awtry substantially contributed to drafting the manuscript. All authors revised it critically. All authors read and approved the final version of the manuscript.




Publication History

Received: 26 July 2024

Accepted: 19 February 2025

Article published online:
08 May 2025

© 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

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