Postoperative bleeding risk for cutaneous surgery in the head and neck region with continued phenprocoumon therapy

Hemorrhagic complications of cutaneous surgery for patients taking antithrombotic therapy: a systematic review and meta-analysis

Cutaneous operations are generally safe procedures with minimal major risks. Excessive bleeding occasionally occurs, especially for patients taking antithrombotic medications. Conversely, stopping these medications before cutaneous surgery may increase the risk of a thromboembolic event. We aimed to synthesize the evidence regarding the risk of hemorrhage and thromboembolic events for patients undergoing cutaneous surgery while taking antithrombotic therapy. We performed a comprehensive search to identify randomized controlled trials and cohort studies that compared rates of hemorrhage and/or thromboembolic events between patients receiving antithrombotic therapy at cutaneous surgery and patients not receiving it. Odds ratio (OR) and risk difference for complications were calculated with random-effects models. Of 9214 patients taking anticoagulant or antiplatelet medications, 323 (3.5%) had hemorrhagic complications; of 21,696 control patients, 265 (1.2%) had hemorrhagic complications. Patients taking antithrombotic therapy had increased bleeding risk relative to control patients (OR 2.63 [95% CI 1.90-3.63]; P < 0.001) and an increased but less clinically important risk difference (OR 0.02 [95% CI 0.01-0.03]; P < 0.001) with high heterogeneity. No difference was observed in hemorrhage rates among patients whose antithrombotic therapy was stopped vs continued (OR 1.16 [95% CI 0.73-1.83]; P = 0.54). No difference was seen in rates of thromboembolic events among patients taking antithrombotic therapy vs control patients. However, two serious thromboembolic events were noted in a cohort of 59 patients whose antithrombotic therapy was stopped. Because of potentially devastating effects of thromboembolic events, the current accepted practice is indicated for continuation of antithrombotic therapy for patients undergoing cutaneous surgery.

Antithrombotic treatment and risk of complications after head and neck full thickness skin graft surgery

Head and neck skin cancer surgery using a full thickness skin graft is a common procedure. Evidence concerning the effects of perioperative antithrombotic treatment on complications is limited. The aim of this study was to evaluate whether perioperative antithrombotic treatment is associated with risk of necrosis, bleeding or infection after full thickness skin graft surgery. Retrospective single-center cohort study with medical records review. Patients operated with a head and neck full thickness skin graft in 2010 and 2013-2015 had available data and were included. Any antithrombotic treatment was continued and all patients were routinely followed-up on days 7-10 after surgery. Data on demographics, concurrent disease, clinical characteristics, antithrombotic medications and postoperative necrosis, bleeding and infection were collected from electronic medical records. Associations with complications were examined using multivariate logistic regression adjusted for age, sex, reoperation, size of excision, site of surgery and concurrent disease. In total, 302 patients (53% women) were included. Antithrombotic treatment (n = 125 patients) was not associated with higher adjusted risk of total complications in multivariate analysis (OR 0.70; 95% CI: 0.34-1.46). In subgroup analyses, the total risk was not increased in patients on aspirin (OR 0.76; 95% CI: 0.39-1.48) or warfarin (OR 1.20; 95% CI: 0.47-3.10). In the warfarin subgroup (N = 26), there was a statistically non-significant trend towards increased risk of graft necrosis. This study supports that aspirin and warfarin should not be discontinued prior to head and neck full thickness skin graft surgery.

[Dermatologic surgery, hemophilia and Von Willebrand disease]

BACKGROUND

Von Willebrand disease (VWD) and hemophilia A and B are the most common types of hereditary coagulation-factor deficiencies. The frequency and type of complications of skin surgery in these patients are unknown. The increasing incidence of skin cancer prompted us to reflect upon this issue. While the incidence of skin cancer is increasing, the complications of skin surgery or ablative laser treatment remain unknown in this population.

AIM

The aim of this study was to determine the frequency of bleeding complications during and after skin surgery in patients with a hereditary coagulation-factor deficiency (hemophilia or VWD).

PATIENTS AND METHODS

We conducted a retrospective study in patients with hemophilia A or B or VWD undergoing skin surgery or ablative laser treatment at the Dermatology Department of the Cochin Hospital in Paris, France.

RESULTS

Fourteen procedures were performed in 8 patients. Three episodes of bleeding occurred (n=3/14, 21.4%): one hematoma, one delayed bleed and one immediate bleed. None of these complications required surgical revision or resuscitation.

DISCUSSION

The rate of hemorrhagic complications was higher than in the general population. However, these complications can be considered non-serious and the risk-benefit ratio remains favorable. Multidisciplinary management and coordination with the reference hemophilia center are mandatory in this population to establish a coagulation-factor (CF) substitution protocol suited to the disease characteristics and the surgical procedure.

Perioperative management of new oral anticoagulants in patients undergoing elective surgery at a tertiary hospital

BACKGROUND

Increasing numbers of patients receiving new oral anticoagulants (NOAC) are undergoing elective surgery. The extent to which perioperative interruption of NOAC therapy and use of bridging heparin are concordant with best evidence is uncertain.

AIMS

To determine: (i) concordance of NOAC and bridging heparin use with guidelines; and (ii) associations between guideline concordance and patient characteristics, surgical factors and perioperative adverse events.

METHODS

Retrospective study of consecutive adult patients undergoing elective surgery at a tertiary hospital between 1 January 2014 and 30 June 2015 and were receiving NOAC for at least 3 months prior to surgery. Concordance of perioperative anticoagulation management with hospital guidelines was rated by two independent researchers according to explicit thrombosis and bleeding risk tables.

RESULTS

One hundred and fifty patients of mean (±SD) age 72.0 (±11.6) years were studied; 75% had atrial fibrillation as NOAC indication. Decision to interrupt anticoagulation in 142 patients was rated guideline-concordant in 59 (41.5%) based on low bleeding risk in all cases and high thrombotic risk in one-third. Concordant decisions were associated with past myocardial infarction (P = 0.009), chronic kidney disease (P = 0.05), use of dabigatran (P = 0.06) and major surgery (P < 0.001). Bridging heparin was prescribed in 51 (35.9%) patients and not prescribed in 91 (64.1%), with 64 (45.1%) decisions rated guideline-discordant comprising 27 decisions to prescribe and 37 not to prescribe. Guideline concordant bridging was associated with chronic kidney disease (P = 0.02); discordant bridging with use of dabigatran (P = 0.04), high thrombotic risk (P = 0.004), past ischaemic stroke (P = 0.07). At 30 days, only one adverse event (major bleed) was noted.

CONCLUSION

Considerable discordance exists between guideline recommendations and perioperative NOAC management. Assistive tools are required that better align decision-making with current best practice.

Periprocedural management of patients receiving a vitamin K antagonist or a direct oral anticoagulant requiring an elective procedure or surgery

The periprocedural management of patients receiving chronic therapy with oral anticoagulants (OACs), including vitamin K antagonists (VKAs) such as warfarin and direct OACs (DOACs), is a common clinical problem. The optimal perioperative management of patients receiving chronic OAC therapy is anchored on four key principles: (i) risk stratification of patient-related and procedure-related risks of thrombosis and bleeding; (ii) the clinical consequences of a thrombotic or bleeding event; (iii) discontinuation and reinitiation of OAC therapy on the basis of the pharmacokinetic properties of each agent; and (iv) whether aggressive management such as the use of periprocedural heparin bridging has advantages for the prevention of postoperative thromboembolism at the cost of a possible increase in bleeding risk. Recent data from randomized trials in patients receiving VKAs undergoing pacemaker/defibrillator implantation or using heparin bridging therapy for elective procedures or surgeries can now inform best practice. There are also emerging data on periprocedural outcomes in the DOAC trials for patients with non-valvular atrial fibrillation. This review summarizes the evidence for the periprocedural management of patients receiving chronic OAC therapy, focusing on recent randomized trials and large outcome studies, to address three key clinical scenarios: (i) can OAC therapy be safely continued for minor procedures or surgeries; (ii) if therapy with VKAs (especially warfarin) needs to be temporarily interrupted for an elective procedure/surgery, is heparin bridging necessary; and (iii) what is the optimal periprocedural management of the DOACs? In answering these questions, we aim to provide updated clinical guidance for the periprocedural management of patients receiving VKA or DOAC therapy, including the use of heparin bridging.

[ENT surgery in patients with anticoagulants and platelet aggregation inhibitors]

BACKGROUND

Patients with antiplatelet and antithrombotic therapy (AP/AT) represent a substantial proportion of ear, nose and throat (ENT) patients. Despite the ubiquitous consideration of bleeding and ischemic/thrombembolic risk, no detailed assessment of the perioperative setting in an ENT cohort is available in the literature.

OBJECTIVES

The goal of the present work is to give a detailed assessment of patients with AP/AT in an ENT cohort resulting in ENT-specific recommendations for daily routine.

MATERIALS AND METHODS

In all, 400 randomized patients were asked regarding analgetic therapy in acute pain. Medical data of 5211 patients who underwent head and neck surgery were analyzed for AP/AT therapy. Therapeutic strategies, the perioperative AP/AT therapy, duration of intensive care treatment and hospitalization (ICT/H), application of erythrocytes and internistic/neurolocigal complication data were analyzed in patients with/without AP/AT.

RESULTS

Nearly 75 % of our patients were taking AP/AT due to coronary heart disease (CHD), peripheral arterial disease (PAD), cardiac arrhythmia, or cardiovascular disease (CVD). Patients' questionnaire revealed that 31 % of our patients use acetylsalicylic acid in acute pain, which represents 10 % of the overall AP/AT cohort. Head and neck surgery in patients with AP/AT showed an elevated bleeding frequency (p = 0.006) without an elevated risk for internistic/neurological complications. ICT/H were remarkably prolonged (p = 0.006; p = 0.0004).

DISCUSSION

Head and neck surgery in patients with AP/AT can be routinely performed. Indication for intensive care, endotracheal intubation, and tracheostomy should be made generously due to high requirements of airway management in ENT. Ischemic/thrombembolic and bleeding risk requires careful assessment in an interdisciplinary setting.

Complications in skin grafts when continuing antithrombotic therapy prior to cutaneous surgery requiring skin grafting: A systematic review

The risk of postoperative bleeding and wound healing complications in skin grafts among anticoagulated patients undergoing cutaneous surgery has not been firmly established. The objective was to examine the literature and assess the risk of postoperative bleeding or wound healing complications in skin grafts among anticoagulated patients, compared with patients who discontinue or patients who are not receiving antithrombotic therapy prior to cutaneous surgery requiring skin grafting. A systematic review examining the effect of antithrombotic therapy on cutaneous surgery was performed according to the PRISMA-guidelines. PubMed and Embase databases were primarily searched for relevant literature in the period from the start date of each database to 2014. A total of eight studies representing 443 patients met criteria for inclusion. No randomised controlled trials were found; the included studies were of prospective and retrospective design. Most of the reviewed studies suggest that the use of antithrombotic therapy can increase the risk of bleeding complications in skin grafts. These complications are only wound threatening and not life threatening. Therefore, this is of concern mostly in terms of hemostasis by the surgeon and good pressure dressings. Care should be taken when operating on anticoagulated patients undergoing cutaneous surgery requiring skin grafting. However, graft failure is rare and, given the risk of thrombotic events, the reviewed studies recommend continuing all medically necessary antithrombotic therapy. The limitations of this study are the small sample sizes and the level of evidence; hence, more research is needed to substantiate these preliminary findings.