Thrombus occlusion in the cardiopulmonary bypass (CPB) circuit is a life-threatening adverse event. Herein, the authors present a case of Stanford type A aortic dissection in which the CPB circuit became completely occluded intraoperatively, necessitating immediate circuit replacement. The patient preoperatively had been prescribed edoxaban, a direct oral anticoagulant (DOAC). Due to the evident preoperative tendency for bleeding, the authors decided to administer andexanet alfa to antagonize the effects of edoxaban. Andexanet alfa, a modified recombinant decoy protein, binds factor Xa inhibitors and rapidly reverses their anticoagulant effects. 

Although there are several reports on heparin resistance in cardiac surgeries using CPB after the administration of andexanet alfa, in this patient, it led to thrombus occlusion of the CPB circuit and may have been associated with cerebral vascular accidents.