Should anticoagulants be stopped before undergoing dermatological surgery?

by Verónica Ruiz

SHOULD ANTICOAGULANTS BE STOPPED BEFORE UNDERGOING DERMATOLOGICAL SURGERY?

Due to the progressive increase in life expectancy, many patients have cardiovascular diseases that require taking drugs that prevent the formation of clots or thrombi, antithrombotic drugs.

It is estimated that between 30-40% of the patients that go through skin surgery take at least 1 antithrombotic agent, most frequently aspirin or acenocoumarol (Sintrom®).

Which are the most frequent antithrombotic drugs used??

We can divide these type of drugs into two main categories:

  • Antiplatelets: They are mainly 3: aspirin, clopidogrel and ticlopidine.

    The effects of all of them last for the life of the platelets (7-10 days). They exert their main activity by preventing platelets from aggregating, thus preventing the formation of the clot.

  • Anticoagulants: They exert their activity by inhibiting some step in the coagulation cascade.

  • Vitamin K antagonists: They are mainly 2: warfarin and acenocoumarol (Sintrom®). The effects of the warfarin can be reversed by the administration of oral vitamin K, fresh frozen plasma or recombinant factor Vlla.they inhibit the synthesis of those vitamin dependent coagulation factors, with factor VII being the most susceptible.
  • Indirect thrombin inhibitors: It is Heparin: The effects of the Heparin can be reversed through the administration of protamine sulfate.
  • Direct thrombin inhibitors: These are most of the new oral anticoagulants and there are mainly 3: Dabigatran, Argatroban y Lepirudin.
  • Direct inhibitors factor Xa: they also belong to the new oral anticoagulants like Rivaroxaban.

 

What is the baseline risk of bleeding complications in patients not taking antithrombotics?

The dermatological surgery, simple or complex, is considered a process that presents a low risk of complications. Although in the more complex surgical procedures there may be an increased risk of bleeding, the possibility that a hemorrhagic complication is life threatening in this type of setting it`s extremely impossible.

“The risk of postoperative bleeding or hematoma formation in dermatological surgery for these patients is approximately 1,4% and life threatening complications have still not being documented”.

What is the risk of bleeding complications in dermatological surgery for patients who TAKE ANTITHROMBOTICS?

Warfarin confers a 7-9 times risk of bleeding and clopidogrel increases the risk 6-8 times, the combination of 2 or more agents carries an additional risk of bleeding. 

Generally, it is observed in many cases but nit in all, an increase in bleeding during the intervention in patients who are taking antithrombotics (regardless of what they have suspended or not); however, the bleeding that occurs during surgery can usually be controlled by suture or electrocoagulation without significant complications.

“The evidence published reveals that there is no significant increased risk of bleeding in patients undergoing dermatological surgery while taking antithrombotics”.

 

Does the temporary interruption of antithrombotics prior to the surgery reduce the risk of bleeding?

In most cases, there is a tendency to suspend this type of drug before surgery, with the prior agreement of the specialist prescribing the drug.

However, most studies indicate that the perioperative interruption of these drugs carries a potentially higher risk of serious cardiovascular complications, such as a stroke or pulmonary embolism, than of intra-postoperative bleeding.

The evidence in this regard is numerous with aspirin, warfarin and clopidogrel that with the new oral anticoagulants.

More specifically, in our Spanish Mohs surgery registry, we evidenced an increased risk of perioperative bleeding in patients who had large tumors and were taking anticoagulants and/or antiaggregants, and that prior withdrawal of these drugs before surgery had no influence on the appearance of bleeding complications.

There is no standard protocol n the management of antithrombotics before and after the dermatological surgery but some working groups have established a series of general and specific recommendations on the continuation or not of the different antithrombotic drugs before surgery, taking into account each drug and the particular situation of each patient and that you can read below:

Suggested guidelines for perioperative management of oral anticoagulant and antiplatelet.pdf

In some situations where the risk of bleeding is very high due to the antithrombotic medication, delaying the surgery may be considered if circumstances permit.

Summary:

In general, it is not recommended to discontinue antithrombotic therapy before dermatological surgery because the potentially higher risk of serious thrombotic complications would outweigh the less significant risk of bleeding.

However, it would be convenient to individualize the decision-making regarding the management of antithrombotic treatment before the surgery, based on the medical situation of each patient, taking into account the type and number of antithrombotic drugs that they take, associated comorbidities, tumor size and the type of surgical reconstruction planned.

If we consider the withdrawal of the drug(s), it would be coherent and convenient to first consult with the specialist who has prescribed them and with the hemostasis unit within each center to determine and assess the suitability of the withdrawal prior to surgery.

In our experience, whether you continue or not with the antithrombotic therapy, we inform you about a possible bleeding after the operation, applying a good bandage to minimize the risk of bleeding, being able to check the status of the surgical wound in the first 24 – 48 hours after the operation if it is required.

REFERENCES

  • Kovich O, Otley CC. Thrombotic complications related to discontinuation of warfarin and aspirin therapy perioperatively for cutaneous operation. J Am Acad Dermatol. 2003;48:233-237.
  • Kirkorian AY, Moore BL, Siskind J, Marmur ES. Peri-operative management of anticoagulant therapy during cutaneous surgery: 2005 survey of Mohs surgeons. Dermatol Surg 2007;33: 1189–97.
  • Hurst EA, Yu SS, Grekin RC, Neuhaus IM. Bleeding complications in dermatologic surgery. Semin Cutan Med Surg 2007;26:40–6.
  • Bordeaux JS, Martires KJ, Goldberg D, et al. Prospective evaluation of dermatologic surgery complications including patients on multiple antiplatelet and anticoagulant medications. J Am Acad Dermatol. 2011;65:576-583.