Outcome of aspirin use during excision of cutaneous lesions

Perioperative Management of Antithrombotic Therapy: An American College of Chest Physicians Clinical Practice Guideline

BACKGROUND

The American College of Chest Physicians Clinical Practice Guideline on the Perioperative Management of Antithrombotic Therapy addresses 43 Patients-Interventions-Comparators-Outcomes (PICO) questions related to the perioperative management of patients who are receiving long-term oral anticoagulant or antiplatelet therapy and require an elective surgery/procedure. This guideline is separated into four broad categories, encompassing the management of patients who are receiving: (1) a vitamin K antagonist (VKA), mainly warfarin; (2) if receiving a VKA, the use of perioperative heparin bridging, typically with a low-molecular-weight heparin; (3) a direct oral anticoagulant (DOAC); and (4) an antiplatelet drug.

METHODS

Strong or conditional practice recommendations are generated based on high, moderate, low, and very low certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology for clinical practice guidelines.

RESULTS

A multidisciplinary panel generated 44 guideline recommendations for the perioperative management of VKAs, heparin bridging, DOACs, and antiplatelet drugs, of which two are strong recommendations: (1) against the use of heparin bridging in patients with atrial fibrillation; and (2) continuation of VKA therapy in patients having a pacemaker or internal cardiac defibrillator implantation. There are separate recommendations on the perioperative management of patients who are undergoing minor procedures, comprising dental, dermatologic, ophthalmologic, pacemaker/internal cardiac defibrillator implantation, and GI (endoscopic) procedures.

CONCLUSIONS

Substantial new evidence has emerged since the 2012 iteration of these guidelines, especially to inform best practices for the perioperative management of patients who are receiving a VKA and may require heparin bridging, for the perioperative management of patients who are receiving a DOAC, and for patients who are receiving one or more antiplatelet drugs. Despite this new knowledge, uncertainty remains as to best practices for the majority of perioperative management questions.

Risk of complications due to antithrombotic agents in cutaneous surgery: a systematic review and meta-analysis

BACKGROUND AND OBJECTIVES

We aimed to determine the risk of complications during cutaneous surgery for the perioperative discontinuation in comparison to the continuation of antithrombotic agents and the bridging of vitamin K antagonists with heparin in comparison to their continuation.

METHODS

We conducted a systematic review, searching three databases for eligible studies. Methods followed the Cochrane Handbook. We used RoB 2 and ROBINS-I to assess risk of bias. The quality of evidence was judged (GRADE). Fixed-effect meta-analyses were performed.

RESULTS

Two randomized-controlled trials and 19 prospective cohort studies were included. It is uncertain whether, compared to its discontinuation, continuing acetylsalicylic acid (risk difference (RD) 0.004, 95 % confidence interval (CI) -0.003 to 0.019) perioperatively increases the risk of significant postoperative bleedings (SPB). Compared to its discontinuation, continuing phenprocoumon perioperatively may increase the risk of SPB (RD 0.02, 95 % CI 0.00 to 0.05). Bridging phenprocoumon with heparin perioperatively may increase the risk of SPB when compared to its continuation (RD 0.07, 95 % CI 0.01 to 0.22). No evidence was found regarding bleeding risks for direct oral anticoagulants.

CONCLUSIONS

No clear indications of major risks of bleedings when continuing antithrombotic agents during minor skin surgeries were identified. However, the quality of evidence was very low.

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.

Continuous Aspirin Use Does Not Increase Bleeding Risk of Split-Thickness Skin Transplantation Repair to Chronic Wounds

BACKGROUND

Discontinuation of aspirin therapy before cutaneous surgery may cause serious complications.

OBJECTIVES

The aim of this prospective study was to evaluate the bleeding risk of split-thickness skin transplantation repair to chronic wounds in patients on aspirin therapy.

METHODS

A total of 97 patients who underwent split-thickness skin transplantation surgery of chronic wounds during a 2-year period were enrolled. They were categorized on the basis of aspirin therapies. The primary outcome was postoperative bleeding and bleeding complications. Univariate analysis was performed to examine the association between aspirin and bleeding complications. Among the 26 patients taking aspirin continuously in group A, there were 5 bleeding complications (19.23%). Among the 55 nonusers in group B, there were 10 bleeding complications (18.18%). Among the 16 discontinuous patients in group C, there were 3 bleeding complications (18.75%). No statistical differences were found among the groups ( P = .956). Univariate analysis showed that continuous aspirin use was not significantly associated with bleeding complications (odds ratio, 0.933; 95% confidence interval, 0.283-3.074; P = .910 in the aspirin and control groups) and that discontinuous aspirin use was not significantly associated with bleeding complications (odds ratio, 0.963; 95% confidence interval, 0.230-4.025; P = .959 in the aspirin and control groups; odds ratio, 0.969; 95% confidence interval, 0.198-4.752; P = .969 in the aspirin and discontinuous groups).

CONCLUSIONS

Continuous aspirin use does not produce an additional bleeding risk in patients who undergo split-thickness skin transplantation repair of chronic wounds.

Dental extraction without stopping single or dual antiplatelet therapy: results of a retrospective cohort study

The aim of this study was to investigate the incidence of bleeding after dental extraction without stopping antiplatelet therapy. Postoperative bleeding was assessed in a total of 1271 patients who were divided into two groups: a study group comprising 183 patients on antiplatelet therapy (aspirin 125 patients/185 occasions; clopidogrel 42 patients/65 occasions; dual therapy 16 patients/24 occasions) who underwent 548 dental extractions on 274 occasions, and a control group comprising 1088 patients who were not receiving any antiplatelet or anticoagulant therapy and underwent 2487 dental extractions on 1472 occasions. The incidence of postoperative bleeding was higher in the study group (5/274, 1.8%) than in the control group (10/1472, 0.7%), and also in the dual antiplatelet subgroup (1/24, 4.2%) than in the single antiplatelet subgroups (clopidogrel: 2/65, 3.1%; aspirin: 2/185, 1.1%); however, these differences were not significant. Postoperative bleeding was managed successfully by repacking with Gelfoam impregnated with tranexamic acid powder in 12 patients and by resuturing in three of the control patients undergoing extraction of impacted teeth with flap elevation. These findings indicate that there is no need to interrupt antiplatelet drugs before dental extraction.

Sellar and parasellar tumor removal without discontinuing antithrombotic therapy

OBJECT

Treatment with dual antiplatelet agents associated with coronary stenting procedures and long-term anticoagulant therapy is increasingly common, but the treatment carries risks during surgical procedures. Evidence-based recommendations have proposed discontinuation of antithrombotic treatment or introduction of bridging therapy in some procedures less invasive and with lower risk of bleeding. However, neurosurgical procedures without discontinuation of antithrombotic treatment and perioperative management have received little investigation.

METHODS

Between October 2008 and January 2014, 15 consecutive patients (11 males and 4 females; age range 51–75 years [mean 68.2 years]), with sellar and parasellar tumors were treated through the transsphenoidal approach without discontinuation of antithrombotic therapy. Clinical data were compared with another 15 patients, who underwent transsphenoidal surgeries without preoperative antithrombotic therapy.

RESULTS

Gross-total removal of the tumor or total aspiration of the content of Rathke's cleft cyst was achieved in 13 patients, and subtotal removal was achieved in 1 patient with a small remnant in the cavernous sinus. No difference was found in intraoperative bleeding between the antithrombotic agent group and the control group (mean 255 ml vs 215 ml, Mann-Whitney U-test, p = 0.547), and no patient required transfusion. No difference was found in operation time between the antithrombotic agent group and the control group (167.8 minutes vs 150.0 minutes, Mann-Whitney U-test, p = 0.262). All patients were discharged on postoperative Day 12 without neurological deficits.

CONCLUSIONS

The present study suggests that discontinuation of antithrombotic therapy may be unnecessary before the typical transsphenoidal surgery. Large randomized clinical trials at multiple centers are needed to confirm these findings.

S3 guidelines for the management of anticoagulation in cutaneous surgery

BACKGROUND

An increasing number of patients are being treated with anticoagulants and platelet inhibitors. Whenever surgical procedures of the skin are required, questions arise regarding the perioperative management of anticoagulation.

METHODS

Development of S3 guidelines following the requirements of the Association of Scientific Medical Societies, systematic literature search and analysis, use of GRADE methodology, structured consensus conference using a nominal group process.

RESULTS

During cutaneous surgery, treatment with acetylsalicylic acid (ASA) should be continued if medically necessary. In procedures with a higher risk of bleeding and a positive bleeding history, INR should be determined preoperatively. Surgical procedures of the skin with a higher risk of bleeding should not be performed if the INR is above therapeutic range. Bridging from vitamin K antagonists (VKA) to heparin should not be performed just because of the surgery of the skin. As to direct-acting oral anticoagulants, the last dose should be taken 24 h preoperatively.

CONCLUSIONS

The recommendations issued by the German guidelines group are mostly in line with recommendations provided by other guidelines. The American ìChest-Guidelineì recommends continuing VKAs and acetylsalicylic acid during minor dermatologic procedures. In their guidelines, the German College of General Practitioners and Family Physicians considers an INR of 2 to be adequate in surgical procedures on the skin.

Risk of complications due to anticoagulation during dermatosurgical procedures: a systematic review and meta-analysis

Background Management of anticoagulation and anti-platelet drugs during cutaneous surgery is still a challenge for many dermatologists and standards of care with respect to stopping, continuing or bridging vary widely. Methods We performed a systematic review (Medline, Cochrane Library, until August 27th, 2013) of studies assessing the risk of complications due to anticoagulation during cutaneous surgery. Primary outcomes were mild-moderate and severe postsurgical bleeding. The secondary outcomes were excessive and uncontrollable intraoperative bleeding and other postsurgical complications as wound dehiscence, erythema, wound infection. Results 1.287 publications were identified and 10 studies were included into the review. The frequencies of bleeding in the control groups in general were low (about 1%). In patients on aspirin, increased risks were seen neither with respect to mild-moderate postoperative bleeding (RR 1.1, CI 0.5-2.3), nor with respect to severe bleeding (RR 0.9, CI 0.2-4.6). The studies with patients on warfarin showed a risk for mild-moderate bleeding that was three times as high as in controls (RR 3.2, CI 1.4-7.1) and for severe bleeding that was 15 times higher (RR 14.8, CI 2.7-80.4). In general the study sizes were small and the methodological quality low. Conclusion The risk of bleeding due to a medication with aspirin seems to be negligible. With warfarin, the risk is increased; an exact estimate of the risk increase is difficult to give, because of the lack of sufficient high quality studies. A two-fold increase appears likely, the 15-fold increase is most likely due to statistical reasons arising from the rareness of the event in the small number of included patients. Stopping, bridging or continuing a medication should always be an individual decision. In accordance with guidelines from internal medicine for most patients it will be recommendable to continue with the medication.

Assessment of the risk of haemorrhage and its control following minor oral surgical procedures in patients on anti-platelet therapy: a prospective study

Controversy exists concerning the suspension or maintenance of anti-platelet drugs before elective surgical procedures. We assessed the association of the risk of prolonged postoperative bleeding with anti-platelet therapy by type of minor surgical procedure and the association between anti-platelet therapy and the level of hemostatic measures required. Five hundred and forty-six patients were included in the study group: those on aspirin (n = 310), clopidogrel (n = 97), and aspirin + clopidogrel dual therapy (n = 139); the control group comprised 575 healthy individuals. Cramer's V test was significant (P < 0.05) but showed a weak association between anti-platelet therapy and prolonged immediate postoperative bleeding. Compared to controls, the odds ratio revealed that the risk of prolonged bleeding in the immediate postoperative period was significantly higher with dual therapy, followed by clopidogrel and aspirin. Prolonged bleeding occurred in 22 patients in the study group and 20 in the control group, and was successfully controlled with local hemostatic measures. Fisher's exact test showed a significant association between dual therapy and higher levels of hemostatic measures (P = 0.004; P = 0.035). Prolonged bleeding in patients on anti-platelet therapy was independent of the type of minor surgical procedure. The greatest risk of prolonged bleeding was found in patients on dual therapy; this required higher levels of hemostatic measures.

Achieving hemostasis in dermatology - Part 1: Preoperative, intraoperative, and postoperative management

As dermatological procedures continue to become increasingly complex, improved methods and tools to achieve appropriate hemostasis become necessary. The methods for achieving adequate hemostasis are variable and depend greatly on the type of procedure performed and the unique characteristics of the individual patient. In Part 1 of this review, we discuss the preoperative, intraoperative, and postoperative management of patients undergoing dermatologic surgery. We address oral medications and supplements that affect hemostasis, hemostatic anesthesia, and intraoperative interventions such as suture ligation and heat-generating cautery devices. In Part 2 of this review, we will discuss topical hemostats. The authors conducted an extensive literature review using the following keywords: “hemostasis,” “dermatology,” “dermatological surgery,” “dermatologic sutures,” “electrosurgery,” “hemostatic anesthesia,” and “laser surgery.” Sources for this article were identified by searching the English literature in the Pubmed database for the time period from 1940 to March 2012. A thorough bibliography search was also conducted and key references were examined.

Perioperative management of antithrombotic therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines

BACKGROUND

This guideline addresses the management of patients who are receiving anticoagulant or antiplatelet therapy and require an elective surgery or procedure.

METHODS

The methods herein follow those discussed in the Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines. Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines article of this supplement.

RESULTS

In patients requiring vitamin K antagonist (VKA) interruption before surgery, we recommend stopping VKAs 5 days before surgery instead of a shorter time before surgery (Grade 1B). In patients with a mechanical heart valve, atrial fibrillation, or VTE at high risk for thromboembolism, we suggest bridging anticoagulation instead of no bridging during VKA interruption (Grade 2C); in patients at low risk, we suggest no bridging instead of bridging (Grade 2C). In patients who require a dental procedure, we suggest continuing VKAs with an oral prohemostatic agent or stopping VKAs 2 to 3 days before the procedure instead of alternative strategies (Grade 2C). In moderate- to high-risk patients who are receiving acetylsalicylic acid (ASA) and require noncardiac surgery, we suggest continuing ASA around the time of surgery instead of stopping ASA 7 to 10 days before surgery (Grade 2C). In patients with a coronary stent who require surgery, we recommend deferring surgery > 6 weeks after bare-metal stent placement and > 6 months after drug-eluting stent placement instead of undertaking surgery within these time periods (Grade 1C); in patients requiring surgery within 6 weeks of bare-metal stent placement or within 6 months of drug-eluting stent placement, we suggest continuing antiplatelet therapy perioperatively instead of stopping therapy 7 to 10 days before surgery (Grade 2C).

CONCLUSIONS

Perioperative antithrombotic management is based on risk assessment for thromboembolism and bleeding, and recommended approaches aim to simplify patient management and minimize adverse clinical outcomes.

Antithrombotic management of stroke patients before colonoscopy

BACKGROUND

Uncertainty exists regarding the management of antithrombotic medications in ischemic stroke and transient ischemic attack (TIA) patients around the time of colonoscopy. We sought to evaluate whether there was a difference in adverse events among patients who continued medications and those who had temporary discontinuation.

METHODS

Using a hospital administrative database, electronic charts of patients with a diagnostic code for stroke or TIA and a procedural code for colonoscopy were reviewed. Information collected included baseline demographics, medical history, and antithrombotic medications. Outcome measures were stroke (ischemic and hemorrhagic), myocardial infarction, venous thromboembolism, and major systemic bleeding (i.e., requiring transfusion) up to 4 weeks after the procedure among patients who had medications continued versus temporarily discontinued.

RESULTS

One hundred seventy-seven patients met inclusion criteria. Antithrombotic medication was temporarily discontinued in 42 patients and continued in 135 patients. Comparing patients who had medications held to those who had medications continued, stroke occurred in 1 (2.4%) versus 0 (0%; P = .237) patients; myocardial infarction in no patients in either group; venous thromboembolism in 0 (0%) versus 1 (0.7%; P > .99) patients; and major system bleeding in 2 (4.8%) versus 4 (3.0%; P = .628) patients.

CONCLUSIONS

In this retrospective analysis, there was no significant difference in the occurrence of stroke, myocardial infarction, venous thromboembolism, and major bleeding between patients who had medications continued around the time of colonoscopy versus those who had temporary discontinuation. A prospective, randomized controlled study is warranted to further elucidate this issue.

Prospective evaluation of dermatologic surgery complications including patients on multiple antiplatelet and anticoagulant medications

BACKGROUND

Few prospective studies have evaluated the safety of dermatologic surgery.

OBJECTIVE

We sought to determine rates of bleeding, infection, flap and graft necrosis, and dehiscence in outpatient dermatologic surgery, and to examine their relationship to type of repair, anatomic location of repair, antibiotic use, antiplatelet use, or anticoagulant use.

METHODS

Patients presenting to University of Massachusetts Medical School Dermatology Clinic for surgery during a 15-month period were prospectively entered. Medications, procedures, and complications were recorded.

RESULTS

Of the 1911 patients, 38% were on one anticoagulant or antiplatelet medication, and 8.0% were on two or more. Risk of hemorrhage was 0.89%. Complex repair (odds ratio [OR] = 5.80), graft repair (OR = 7.58), flap repair (OR = 11.93), and partial repair (OR = 43.13) were more likely to result in bleeding than intermediate repair. Patients on both clopidogrel and warfarin were 40 times more likely to have bleeding complications than all others (P = .03). Risk of infection was 1.3%, but was greater than 3% on the genitalia, scalp, back, and leg. Partial flap necrosis occurred in 1.7% of flaps, and partial graft necrosis occurred in 8.6% of grafts. Partial graft necrosis occurred in 20% of grafts on the scalp and 10% of grafts on the nose. All complications resolved without sequelae.

LIMITATIONS

The study was limited to one academic dermatology practice.

CONCLUSION

The rate of complications in dermatologic surgery is low, even when multiple oral anticoagulant and antiplatelet medications are continued, and prophylactic antibiotics are not used. Closure type and use of warfarin or clopidogrel increase bleeding risk. However, these medications should be continued to avoid adverse thrombotic events.

Peri-operative management of ophthalmic patients taking antithrombotic therapy

Increasing number of patients presenting for ophthalmic surgery are using oral anti-coagulant and anti-platelet therapy. The current practice of discontinuing these drugs preoperatively because of a presumed increased risk of bleeding may not be evidence-based and could pose a significant risk to the patient's health. To provide an evidence-based review on the peri-operative management of ophthalmic patients who are taking anti-thrombotic therapy. In addition, we briefly discuss the underlying conditions that necessitate the use of these drugs as well as management of the operative field in anti-coagulated patients. A semi-systematic review of literature was performed. The databases searched included MEDLINE, EMBASE, database of abstracts of reviews of effects (DARE), Cochrane controlled trial register and Cochrane systematic reviews. In addition, the bibliographies of the included papers were also scanned for evidence. The published data suggests that aspirin did not appear to increase the risk of serious postoperative bleeding in any type of ophthalmic surgery. Topical, sub-tenon, peri-bulbar and retrobulbar anaesthesia appear to be safe in patients on anti-thrombotic (warfarin and aspirin) therapy. Warfarin does not increase the risk of significant bleeding in most types of ophthalmic surgery when the INR was within the therapeutic range. Current evidence supports the continued use of aspirin and with some exceptions, warfarin in the peri-operative period. The risk of thrombosis-related complications on disruption of anticoagulation may be higher than the risk of significant bleeding by continuing its use for most types of ophthalmic surgery.

Antiplatelet therapy in the perioperative period

The current practice of withdrawing aspirin 7-10 days preoperatively may be dangerous in certain groups of patients. The risk of cardiovascular events increases 3-fold after aspirin withdrawal. The average time between aspirin withdrawal and the manifestation of acute coronary syndrome is 8 to 11 days. The withdrawal of clopidogrel earlier than 4-6 weeks after bare metal stent implantation or less than 12 months after drug-eluting stent implantation is very risky and poses a high risk of stent thrombosis and high perioperative mortality. Continuing aspirin perioperatively leads to a 1.5-fold increase in perioperative bleeding complications but it does not lead to a higher severity of bleeding complications or higher mortality. The article analyzes current European and American guidelines for perioperative antiplatelet treatment and suggests an algorithm based on the guidelines to help make clinical decisions.

The effect of aspirin on bleeding after extraction of teeth

Acetylsalicylic acid (ASA) generically known as aspirin is used clinically as an analgesic, antipyretic, anti-inflammatory and as a medication to prevent platelet aggregation. Many studies have investigated bleeding associated with ASA.

OBJECTIVE

The aim of this study was to determine if ASA was associated with bleeding after dental extraction.

PATIENTS AND METHODS

One hundred and eighty-nine subjects were divided into four groups. Group 1A subjects who received ASA, underwent simple extraction. Group 1B subjects who received ASA, underwent surgical extraction. Group 2A subjects who did not receive ASA, underwent simple extraction which served as control group. Group 2B subjects who did not receive ASA, underwent surgical extraction which also served as control group.

RESULTS

The results showed that Group 1B was the only group which showed bleeding after 24 h. All groups had similar results after 48 h and 5 days post-operatively.

CONCLUSION

The study concluded that subjects who received 81 mg ASA daily could undergo dental extraction without bleeding risks.

US-guided fine-needle aspiration of thyroid nodules: indications, techniques, results

Fine-needle aspiration (FNA) biopsy of thyroid nodules is minimally invasive and safe and is usually performed on an outpatient basis. However, the optimal application of FNA requires not only technical skill but also an awareness of the limitations of the procedure, the indications for its use, the factors that affect the adequacy of the biopsy specimen, and the postprocedural management strategy. Ultrasonographic (US) features that are considered indications for FNA include single and multiple thyroid nodules. The results of FNA biopsy are operator dependent. In addition, the results may be affected by the lesion characteristics, the accuracy of lesion and needle localization, the method of guidance, the number of aspirated samples, the needle gauge, the aspiration technique, and the presence or absence of on-site facilities for immediate cytologic examination. With regard to postprocedural management, nodules that are diagnosed as benign on the basis of an adequate FNA specimen should be monitored with follow-up US. Circumstances that necessitate repeat FNA include sample inadequacy, nodule enlargement, cyst recurrence, or clinical or imaging findings that arouse suspicion about the presence of a malignancy even when cytologic findings in the biopsy specimen indicate benignity. Supplemental material available at radiographics.rsnajnls.org/cgi/content/full/28/7/1869/DC1.

Bleeding complications in dermatologic surgery

Although the overall incidence is low, bleeding complications in dermatologic surgery can occur and be the source of significant patient morbidity. In this article, we summarize the key aspects of preoperative assessment of patients at risk for bleeding. A review of current issues and literature regarding safe continuation of anticoagulant and antiplatelet medications in dermatologic surgery patients is also presented. In addition, principles for management of bleeding events, should they occur, are also highlighted.

Perioperative Management of Anticoagulant Therapy during Cutaneous Surgery: 2005 Survey of Mohs Surgeons

BACKGROUND

The perioperative management of anticoagulation and antiplatelet therapy is a controversial topic in the field of dermatologic surgery. Dermasurgeons must weigh the risk of bleeding against the risk of thrombotic complications when deciding how to manage perioperative anticoagulation.

OBJECTIVE

Our aim is to present a summary of current practice in anticoagulation management perioperatively during cutaneous surgery. We compare our results to those found in a similar survey in 2002.

METHODS AND MATERIALS

A questionnaire surveying current practice in perioperative management of anticoagulant therapy was mailed to 720 dermasurgeons.

RESULTS

Thirty-eight percent of dermasurgeons responded to the questionnaire. Of the responding physicians, 87% discontinue prophylactic aspirin therapy, 37% discontinue medically necessary aspirin, 44% discontinue warfarin, 77% discontinue nonsteroidal anti-inflammatory drugs (NSAIDs), and 77% discontinue vitamin E therapy perioperatively at least some of the time. Although clopidogrel was not surveyed, 78 physicians included comments about the management of this agent.

CONCLUSION

Dermasurgeons were more likely to continue medically necessary aspirin and warfarin in 2005 compared to 2002, with the most dramatic shift evident in the management of warfarin. They were more likely to discontinue prophylactic aspirin, NSAIDs, and vitamin E. Surgeons were concerned about bleeding with the antiplatelet agent clopidogrel. More evidence-based medicine is necessary to set guidelines for the management of anticoagulation and antiplatelet therapy perioperatively.

Bleeding Complications in Dermatologic Surgery

Although the overall incidence is low, bleeding complications in dermatologic surgery can occur and be the source of significant patient morbidity. In this article, we summarize the key aspects of preoperative assessment of patients at risk for bleeding. A review of current issues and literature regarding safe continuation of anticoagulant and antiplatelet medications in dermatologic surgery patients is also presented. In addition, principles for management of bleeding events, should they occur, are also highlighted.

Discontinuation of perioperative antiplatelet and anticoagulant therapy in stroke patients

Growing evidence suggests that perioperative withdrawal of ASA for secondary stroke prevention increases thromboembolic risk without the associated benefit of decreased bleeding complications. ASA maintenance is acceptable in many procedures, including invasive ones. Many procedures, in particular ophthalmologic, dermatologic, and dental surgeries, also are safe while continuing oral AC. Warfarin has been continued successfully even in some surgeries that have high bleeding risk. When the risk is too high, temporary bridging therapy with LWMH is safe in many populations. Although the exact thromboembolic risks associated with temporary cessation of AP and AC are unknown and likely low, morbidity and mortality associated with thromboembolism are high. Further studies investigating the risks and benefits of maintaining AP and AC during procedures, particularly invasive ones, are needed. Meanwhile, it is critical that physicians understand the risks and benefits of perioperative AP and AC and the variety of procedures in which these agents can be safely continued.

Low-dose aspirin for secondary cardiovascular prevention - cardiovascular risks after its perioperative withdrawal versus bleeding risks with its continuation - review and meta-analysis

OBJECTIVES

Low-dose aspirin given for secondary prevention of cardiovascular disease is frequently withdrawn prior to surgical or diagnostic procedures to reduce bleeding complications. This may expose patients to increased cardiovascular morbidity and mortality. Aim of the study was to review and quantify cardiovascular risks because of periprocedural aspirin withdrawal and bleeding risks with the continuation of aspirin.

METHODS

We screened MEDLINE (January 1970-October 2004) with additional manual cross-referencing for clinical studies, surveys on the opinions of doctors and guidelines.

RESULTS

Studies reporting the relative risk of acute cardiovascular events after aspirin withdrawal when compared with its continuation were not found. However, retrospective investigations revealed that aspirin withdrawal precedes up to 10.2% of acute cardiovascular syndromes. The time interval between discontinuation and acute cerebral events was 14.3 +/- 11.3 days, 8.5 +/- 3.6 days for acute coronary syndromes, and 25.8 +/- 18.1 days for acute peripheral arterial syndromes (P < 0.02 versus acute coronary syndromes). On aspirin-related bleeding risks, we obtained 41 (12 observational retrospective, 19 observational prospective, 10 randomized) studies, reporting on 49 590 patients (14 981 on aspirin). Baseline frequency of bleeding complications varied between 0 (skin lesion excision, cataract surgery) and 75% (transrectal prostate biopsy). Whilst aspirin increased the rate of bleeding complications by factor 1.5 (median, interquartile range: 1.0-2.5), it did not lead to a higher level of the severity of bleeding complications (exception: intracranial surgery, and possibly transurethral prostatectomy). Surveys amongst doctors on the management of this problem demonstrate wide variations. Available guidelines are scarce and in part contradictory.

CONCLUSIONS

Only if low-dose aspirin may cause bleeding risks with increased mortality or sequels comparable with the observed cardiovascular risks after aspirin withdrawal, it should be discontinued prior to an intended operation or procedure. Controlled clinical studies are urgently needed.

Anticoagulation in Elective Surgery

Several categories of patients may be receiving anticoagulation therapy and require surgery. Many patients take cardioprotective aspirin or warfarin for atrial fibrillation, the presence of a mechanical heart valve, prior thromboembolism, a documented left ventricular thrombus, or a history of venous thromboembolism with or without a pulmonary embolism. Inpatients may be receiving injectable forms of anticoagulation to reduce risk of deep venous thrombosis or for other conditions, such as atrial fibrillation. Patients receiving any type of anticoagulation present a problem when they require surgery because the interruption of anticoagulant therapy increases their risk of thromboembolism and stroke (Schanbacher & Bennett, 2000). Rational decisions regarding the appropriateness of perioperative anticoagulation depend on individual patient factors and can only be made when the risk of perioperative thromboembolism is balanced against the risk of perioperative bleeding.