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Intraoperative Unfractionated Heparin Unresponsiveness during Endovascular Repair of a Ruptured Abdominal Aortic Aneurysm following Administration of Andexanet Alfa for the Reversal of Rivaroxaban
Author(s) -
Eche Ifeoma Mary,
Elsamadisi Pansy,
Wex Nicole,
Wyers Mark C.,
Brat Gabriel A.,
Cunningham Katherine,
Bauer Kenneth A.
Publication year - 2019
Publication title -
pharmacotherapy: the journal of human pharmacology and drug therapy
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.227
H-Index - 109
eISSN - 1875-9114
pISSN - 0277-0008
DOI - 10.1002/phar.2306
Subject(s) - medicine , rivaroxaban , abdominal aortic aneurysm , anesthesia , abdominal surgery , heparin , surgery , argatroban , atrial fibrillation , aneurysm , warfarin , cardiology , thrombin , platelet
The authors describe a case of unfractionated heparin ( UFH ) unresponsiveness in the operating room secondary to reversal of rivaroxaban with coagulation factor Xa (recombinant) inactivated‐zhzo (andexanet alfa). A 70‐year‐old man with a known 4.5‐ to 5.0‐cm abdominal aortic aneurysm and atrial fibrillation managed with rivaroxaban presented with severe right‐sided flank pain radiating to the left side of his abdomen. Computed tomography‐angiography on arrival demonstrated a left retroperitoneal hematoma and a suspected ruptured abdominal aortic aneurysm. He received andexanet alfa to reverse rivaroxaban prior to an emergent endovascular aneurysm repair. During surgery, he received a total of 14,000 units (167 units/kg) of UFH with minimal changes in activated clotting time (132–144 sec; baseline 135 sec [reference range 74–137 sec]). This case highlights the potential complications of using UFH anticoagulation following reversal of factor Xa inhibitors with andexanet alfa and underscores the importance of peri‐procedural anticoagulation planning. For patients who require intra‐operative anticoagulation, providers should consider anticoagulation reversal with prothrombin complex concentrate instead of andexanet alfa or administration of a parenteral direct thrombin inhibitor, such as argatroban or bivalirudin during the surgical procedure.