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Andexanet alpha is a reversal agent for the direct factor Xa inhibitors including apixaban and rivaroxaban in situations of life-threatening or uncontrolled bleeding. The effect of andexanet alpha on other anticoagulants including unfractionated heparin is less well described but important to consider particularly in situations of emergency cardiac or vascular surgery cases. The current case report describes the complicated course of anticoagulation for a ruptured abdominal aortic aneurysm operation where andexanet administration resulted in thrombotic complications and need for alternative anticoagulant therapy.