Introduction: Proximal aorta interventions impose significant bleeding risk. Patients on concomitant
anticoagulation regimens compound the risk of bleeding in any surgery, but especially cardiothoracic interventions.
The employment of direct-acting oral anticoagulants (DOAC), namely those that target clotting factors II or
X, has expanded at a precipitous rate over the last decade. The emergence of their reversal agents has followed
slowly, leaving clinicians with management dilemmas in urgent surgery. We discuss current reversal strategies
based on the available published data and our experience with proximal aortic surgery in patients taking DOACs.
Literature Search: We performed a review of literature and present three cases from our experience to offer
insight into management strategies that have been historically successful. A review of literature was conducted
via PubMed with the following search string: (NOAC or DOAC or TSOAC) and (aorta or aortic or (Stanford and
type and a)).
Case Presentation: We present three case presentations that illustrate the importance of DOAC identification and
offer management strategies in mitigating associated bleeding risks in urgent or emergent surgeries.
Conclusion: Treatment teams should be aware of the technical limitations of identifying and reversing DOACs.
In view of the tendency toward publishing positive outcomes, more scientific rigor is required in the area of
emergency DOAC reversal strategies.