Review
Bleeding on the cutting edge: A systematic review of anticoagulant and antiplatelet continuation in minor cutaneous surgery

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Summary

Background

Anticoagulant and antiplatelet (AC/AP) use is common and practice surrounding AC/AP continuation or cessation peri-operatively for minor cutaneous surgery lacks evidence-based consensus.

Objective

To determine the risks of haemorrhagic and thromboembolic complications associated with the continuation or cessation of AC/AP therapy in minor cutaneous surgery.

Methods

A systematic literature search was conducted using PubMed, MEDLINE, Embase and CENTRAL, to identify all articles involving the use of AC/AP in patients undergoing minor cutaneous surgery, including skin grafts and local flaps. Eligible studies were randomised control trials, prospective studies and retrospective studies in the English language. Studies investigating free-flap repairs, oculoplastic surgery and hand surgery were excluded.

Results

30 studies included data from over 14,000 patients, of which more than 5000 took regular AC/AP therapy. Thromboembolic events were rare but carry high morbidity and even mortality, and in these studies three events were associated with cessation of AC/AP. There was no increase in haemorrhagic complications in patients taking aspirin monotherapy, but evidence is conflicting regarding warfarin and clopidogrel monotherapy, which shows a small increase in rate of bleeding complications. However, no increase in wound dehiscence, graft failure, wound infection or cosmetic outcome was seen. Too few studies investigated DOAC use to draw reliable conclusions. Data are sparse in comparing multiple versus single AC/AP regimens. Use of skin grafts or local flaps may have a greater complication rate than direct closure in patients on one or more AC/AP, but evidence is limited.

Conclusion

A case-by-case risk assessment is warranted in all patients but where possible, clinicians should prioritise meticulous haemostasis over cessation of agents.

Section snippets

Background

Anticoagulant and antiplatelet (AC/AP) use is common. Aspirin is the fourth most widely used medicine in the United Kingdom (UK), prescribed 28 million times in 2015.1 Warfarin was prescribed 11.6 million times in the same year, which has doubled since 2005.1 The modification of AC/AP doses in the perioperative period of minor cutaneous surgery requires a careful assessment of bleeding and thromboembolic risk.

Practice is highly variable and changing. A 2002 survey of United States (US)

Objective

To determine the risks of haemorrhagic and thromboembolic complications associated with the continuation or cessation of anticoagulant and antiplatelet therapy in the setting of minor cutaneous surgery.

Search strategy

This review was conducted according to guidelines set forth in the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) and was registered with PROSPERO (University of York, registration number: CRD42017063756).

A systematic literature search was conducted using PubMed, MEDLINE and Embase using the OVID interface, and Cochrane Central Register of Controlled Trials (CENTRAL), to identify all articles involving the use of anticoagulant and/or antiplatelet therapy (AC/AP) in

Results

A total of 30 studies were deemed eligible, including one double-blinded RCT, one non-blinded RCT, 18 prospective cohort studies and 10 retrospective observational studies (Figure 1). These include data on at least 14,994 patients undergoing more than 19,771 minor cutaneous operations.

The mean subject age of the patients in the AC/AP exposed group ranged from 51.5 to 79 years and from 44.4 to 76 years in the non-exposed control groups. Where the surgical site was reported, the majority of cases

Main findings

This systematic review of the literature drew from 30 studies, and more than 14,000 patients undergoing minor cutaneous surgery. Across all these studies, thromboembolic events were rare, following cessation of anticoagulants or antiplatelet (AC/AP) agents, this occurred in three patients but all resulted in significant morbidity.34, 35

The evidence reviewed, firmly supports the continuation of aspirin therapy in all minor cutaneous surgery as patients on aspirin monotherapy are at no greater

Conclusion

Thromboembolic events associated with cessation of anticoagulants and antiplatelets, while infrequent, are devastating. No increase in haemorrhagic complication rate is seen in patients taking aspirin monotherapy. Evidence is conflicting for warfarin and clopidogrel monotherapy but they are both likely associated with a small increase in rate of bleeding complications, but with no increased rates of wound dehiscence, graft failure, wound infection or cosmetic outcome. Only one small study has

Conflict of interest statement

The authors certify that they have no affiliations with or involvement in any organisation or entity with any financial interest or non-financial interest in the subject matter or materials discussed in this manuscript.

Funding

None.

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