A Case of Successful Hemostasis after Andexanet Alfa Administration for Critical Postoperative Lower Extremity Bleeding

Nanako OKANO; Takako Migita; Akiko Egi; Kuniko Okada; Tomoaki Miki; Miyou Kimura

doi:10.2199/jjsca.45.552

November 15, 2025THE JOURNAL OF JAPAN SOCIETY FOR CLINICAL ANESTHESIAOpen Access

A Case of Successful Hemostasis after Andexanet Alfa Administration for Critical Postoperative Lower Extremity Bleeding

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Why the study?

Does administration of andexanet alfa achieve hemostasis in a patient with critical postoperative lower extremity bleeding associated with edoxaban?

Key Points

To describe a case of life-threatening postoperative hemorrhage following lower extremity surgery in a patient receiving edoxaban that was successfully managed with the reversal agent andexanet alfa.
Case report of a female in her 50s with antiphospholipid syndrome and diabetic nephrotic syndrome who underwent arthroscopic debridement and irrigation for septic knee arthritis.
Edoxaban (30 mg) was resumed on postoperative day 1, triggering massive hemorrhage and shock requiring massive transfusion (22 units of red blood cells and 12 units of fresh frozen plasma).
Andexanet alfa was administered as an initial 400 mg bolus followed by a continuous infusion of 480 mg over 2 hours, alongside emergency surgical hemostasis.
Following total postoperative blood loss reaching 6,830 mL, emergency direct surgery achieved hemostasis with only 193 mL of intraoperative bleeding.
Coagulation parameters recovered, with hemoglobin improving to 8.1 g/dL, prothrombin time to 84.4%, and PT-INR normalizing to 1.10.
The patient was discharged on postoperative day 37 without experiencing any thromboembolic complications.

Structured PICO

Does administration of andexanet alfa achieve hemostasis in a patient with critical postoperative lower extremity bleeding associated with edoxaban?

P

Population

1 female patient in her 50s in Japan with critical postoperative bleeding (6,830 mL total) and shock following arthroscopic debridement and lavage for right septic knee arthritis while taking edoxaban 30 mg and aspirin 100 mg. Past medical history included type 2 diabetes mellitus, diabetic nephrotic syndrome, hypertension, antiphospholipid syndrome, essential thrombocythemia, and prior left lower extremity arterial embolism requiring amputation.

I

Intervention

Andexanet alfa 400 mg IV bolus followed by 480 mg continuous IV infusion over 2 hours (Regimen A), combined with open surgical hemostasis and blood transfusions (22 units RBC, 12 units FFP).

O

Outcome

Successful surgical and clinical hemostasis with hemodynamic stabilizationhard clinical

Limitations

Single case report
Anti-Xa activity and edoxaban blood concentrations were not measured to quantitatively guide reversal
Potential confounding effect of preoperative aspirin on platelet function
Delay in obtaining andexanet alfa due to the drug not being on the hospital formulary at the time

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Implication

Andexanet alfa effectively achieved hemostasis in a case of life-threatening postoperative orthopedic bleeding associated with edoxaban and worsening renal function, even when administered more than 24 hours after the last DOAC dose.

Abstract

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Cite This Study

OKANO et al. (2025) studied this question.

synapsesocial.com/papers/6af9d089c9a92bd5bbc78503 https://doi.org/10.2199/jjsca.45.552

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A Case of Successful Hemostasis after Andexanet Alfa Administration for Critical Postoperative Lower Extremity Bleeding

Key Points

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

A Case of Successful Hemostasis after Andexanet Alfa Administration for Critical Postoperative Lower Extremity Bleeding

Key Points

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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