Bleeding and thromboembolic risk in patients under anticoagulant therapy receiving oral surgery: a systematic review

The effect of anticoagulation therapy on the surgical outcomes of minimally invasive major gastrointestinal surgery

BACKGROUND

The surgical outcomes of minimally invasive surgery (MIS) for gastrointestinal (GI) cancers in patients receiving anticoagulation therapy (ACT) are unknown. We investigated the effect of ACT on the surgical outcomes of minimally invasive major GI surgery, with a particular focus on postoperative bleeding and thromboembolic complications.

METHODS

A total of consecutive 1290 patients undergoing elective minimally invasive (laparoscopic and robotic) major GI surgery (esophagogastric and colorectal resection for malignancy) between 2014 and 2023 were enrolled. The patients were divided into three groups: patients without receiving anticoagulation therapy (non-ACT, n = 1076), patients receiving direct oral anticoagulants (DOAC, n = 144), and patients receiving warfarin (WF, n = 70). Outcome variables were compared between the groups and the risk factors of postoperative bleeding complications were assessed using logistic multivariate analysis.

RESULTS

The overall rate of thromboembolic complication was 0.5%, and the operative mortality was zero in the whole cohort. The incidences of postoperative bleeding in the non-ACT, DOAC, and WF groups were 1.0%, 6.9% and 11.4%, respectively (P < 0.001). Among 8 DOAC-received patients with postoperative GI bleeding, 75% of cases occurred on postoperative day 5 or later. Multivariate analysis showed DOAC (odds ratio = 5.420, P < 0.001) and perioperative heparinization (odds ratio = 3.770, P = 0.048) were significant risk factors for major postoperative bleeding.

CONCLUSIONS

Although minimally invasive major GI surgery can be safely performed in patients receiving ACT, attention should be paid for the occurrence of delayed GI bleeding especially in the DOAC-received patients. Patients treated with DOAC or perioperative heparinization still represent a challenging group in the present cohort, and need to be carefully managed.

Influence of antiplatelet medication and anticoagulation therapy after dental extractions on hospitalization: a retrospective 10-year study

BACKGROUND

The aim of this retrospective study was to identify high-risk dental extraction patients and the timing of postoperative hemorrhage to evaluate whether preventive hospitalization should be considered in patients on antiplatelet medication (AP) or anticoagulants.

METHODS

Our study included 1595 procedures; 1319 were conducted under monotherapy (Group I: AP; Group II: indirect oral anticoagulant [IAC]; Group III: direct oral anticoagulant [DOAC]) and 276 under dual therapy (Group IV: double AP; Group V: AP and IAC; Group VI: AP and DOAC). We evaluated the incidence, frequency and timing of hemorrhage, hospitalization rate, and treatment of bleeding incidents.

RESULTS

The incidence of hemorrhagic events was significantly higher in the dual therapy groups compared to the monotherapy groups (p < 0.001). Comparing the procedures under monotherapy, those on DOAC (Group III) had a significantly higher risk of postoperative bleeding than Groups I and II (p < 0.001) and a higher rate of repeated bleeding episodes (p = 0.035). Regarding bleeding incidents, 44% (dual therapy) vs. 51.1% (monotherapy) occurred on the day of surgery.

CONCLUSIONS

The bleeding risk after dental extractions is overall low and patients were often hospitalized preventively due to their comorbidities rather than actual bleeding risk. Patients should be instructed about local compression, and surgeries should be completed in the morning to avoid emergency visits. However, patients with cardiovascular diseases and dual therapy had a higher risk of postoperative hemorrhage. Thus, hospitalization is to be considered in these cases.

TRIAL REGISTRATION

The study was approved by the Ethics Committee of the Medical Faculty of RWTH Aachen (Decision Number 24-136). This was a retrospective clinical study designed to analyze postoperative bleeding and hospitalization rates after dental extractions in patients on AP or anticoagulation therapy.

Platelet-rich fibrin as a hemostatic agent in dental extractions in patients taking anticoagulants or antiplatelet medication: a systematic review

OBJECTIVES

The aim of this systematic review was to evaluate whether platelet-rich-fibrin (PRF) is effective in preventing postoperative bleeding after dental extractions in patients on anticoagulation or antiplatelet therapy compared to stitches alone and different hemostatic agents.

MATERIALS AND METHODS

This systematic review was conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The protocol was registered at the International Prospective Register of Systematic Reviews (PROSPERO) (registration number CRD42024562289). Two authors independently performed searches in several databases, including PubMed, EMBASE, Cochrane Library, and SCOPUS.

RESULTS

In total, 789 studies were identified, of which 11 met the inclusion criteria after full-text screening. Four studies evaluated the efficiency of PRF in patients on antiplatelet therapy, and seven studies analyzed its hemostatic effect in patients on anticoagulants. All studies showed sufficient hemostasis when PRF was used, but due to heterogeneity meta-analysis was not possible.

CONCLUSIONS

Despite the use of different protocols and control groups, PRF treatment seems to be superior to only stitches and inferior to chitosan dressings concerning the time of hemostasis. Additionally, PRF seems to be beneficial in terms of faster wound healing and less postoperative pain.

CLINICAL RELEVANCE

PRF is known to enhance soft tissue healing and reduce postoperative pain. As a fully autologous platelet concentrate, it can support hemostasis after dental extractions in patients on antiplatelet or anticoagulation therapy. This systematic review aims to provide an update of the existing literature on PRF and its hemostatic capacity in patients with blood thinning medication.

New High-Affinity Thrombin Aptamers for Advancing Coagulation Therapy: Balancing Thrombin Inhibition for Clot Prevention and Effective Bleeding Management with Antidote

Thrombin is a key enzyme involved in blood clotting, and its dysregulation can lead to thrombotic diseases such as stroke, myocardial infarction, and deep vein thrombosis. Thrombin aptamers have the potential to be used as therapeutic agents to prevent or treat thrombotic diseases. Thrombin DNA aptamers developed in our laboratory exhibit high affinity and specificity to thrombin. In vitro assays have demonstrated their efficacy by significantly decreasing Factor II activity and increasing PT and APTT times in both plasma and whole blood. Aptamers AYA1809002 and AYA1809004, the two most potent aptamers, exhibit high affinity for their target, with affinity constants (Kd) of 10 nM and 13 nM, respectively. Furthermore, the in vitro activity of these aptamers displays dose-dependent behavior, highlighting their efficacy in a concentration-dependent manner. In vitro stability assessments reveal that the aptamers remain stable in plasma and whole blood for up to 24 h. This finding is crucial for their potential application in clinical settings. Importantly, the thrombin inhibitory activity of the aptamers can be reversed by employing reverse complement sequences, providing a mechanism to counteract their anticoagulant effects when necessary to avoid excessive bleeding. These thrombin aptamers have been determined to be safe, with no observed mutagenic or immunogenic effects. Overall, these findings highlight the promising characteristics of these newly developed thrombin DNA aptamers, emphasizing their potential for therapeutic applications in the field of anticoagulation therapy. Moreover, the inclusion of an antidote in the coagulation therapy regimen can improve patient safety, ensure greater therapeutic efficacy, and minimize risk during emergency situations.