Dana-Farber Cancer Institute, Brigham and Woman’s Hospital, Harvard Medical School, Boston, MA, USA
There is no consensus with regard to perioperative blood thinner management in patients undergoing cutaneous procedures. The rationale and problems associated with blood thinners during cutaneous surgery are examined and the preoperative screening and surgical management of patients taking anticoagulant medicines discussed. There are many studies that support continuation of blood thinners during cutaneous procedures supporting the conclusion that blood thinners should not be discontinued for cutaneous procedures.
Key Words: blood thinners, cutaneous surgery
Anticoagulant medicines are used to treat individuals at risk for primary or recurrent thromboembolism. During major procedures, such as intraabdominal, intracranial, orthopedic or cardiothoracic, blood thinning agents are usually discontinued or at least modified in an attempt to prevent undue intraoperative and postoperative bleeding. Subsequent to such procedures, blood thinners are reintroduced to treat the underlying thromboembolic disorder. This process of manipulating the level of anticoagulation can be time consuming, requires multiple blood tests and exposes patients to increased risk of thromboembolism, hemorrhage or both.
Patients at risk for thromboembolic events include those with mechanical heart valve(s), valvular heart disease, underlying coagulopathy, atrial fibrillation, history of stroke, pulmonary embolism, myocardial infarction, or deep venous thrombosis. Commonly prescribed anticoagulant medicines include antithrombin agents such as warfarin or heparin products, and antiplatelet agents such as aspirin, thienopyridines or glycoprotein IIb/IIIa inhibitors (Table 1). Patients at risk for thromboembolism typically take one or more of the aforementioned anticoagulants under the guidance of the primary care provider.
|ADP induced platelet activation inhibitors||Clopidogrel (Plavix®)|
|Antithrombin agents||Unfractionated heparin||——|
|Direct thrombin inhibitors||Bivalirudin (Angiomax™)|
|Low molecular weight heparin||Enoxaparin (Lovenox®)|
|Factor Xa inhibitor||Fondaparinux (Arixtra®)|
|Thrombolytic agents||Plasminogen activators||Streptokinase (Streptase®)|
Historically, dermatologic surgeons have implemented general surgery practice guidelines in managing blood thinning medicines prior to and during cutaneous procedures. Based on advice given for previous surgery, some patients undergoing cutaneous surgery stop anticoagulation medicines themselves without consulting a physician. Other patients stop anticoagulant medicines on the advice of their referring physician, surgeon or both. Frequently patients on long-term anticoagulation arrive for their cutaneous procedures without the protection afforded by their vital blood thinning medicines. Thromboenbolic events have been reported in cutaneous procedure patients whose anticoagulants were stopped in order to limit ostensible perioperative bleeding.2 A recent survey of 168 Mohs micrographic surgeons reported 46 patients who experienced thromboembolic events, including three deaths and 24 strokes after brief perioperative blood thinner cessation.3 Fifty-four percent of the thromboembolic events occurred after warfarin was discontinued and 39% had thromboembolism after aspirin was withheld.3 Discontinuation of newer blood thinners such as ticlopidine, clopidogrel and ardeparin has also been associated with thromboembolism.1
A retrospective study of 653 patients undergoing cutaneous procedures was performed by Otley, et al in 1996. Some of the patients had their blood thinners (antiplatelet agent or warfarin) discontinued preoperatively. The risk of severe intraoperative and postoperative bleeding in patients taking blood thinners was found very low, not significantly reduced by preoperative blood thinner discontinuation.4 Several recent studies have documented that cutaneous procedure patients taking aspirin have no significant risk of postoperative hemorrhagic complications.5-7 Others have reported no significant risk of postoperative hemorrhage in cutaneous surgery patients taking therapeutic doses of warfarin.8,9 Furthermore, successful procedures in patients taking therapeutic levels of warfarin without undue postoperative bleeding have been documented in many surgical subspecialties, including cardiothoracic, gastrointestinal, urology, oromaxillofacial, vascular, and ophthalmology.
Cutaneous surgeons may cite anecdotal experience as grounds for blood thinner discontinuation. Some surgeons believe blood thinners cause undue intraoperative bleeding, which interferes with operative dissection. Perceiving undue intraoperative bleeding, the surgeon may inquire as to whether the patient has recently taken blood-thinning medicines. A recent study by West, et al showed that cutaneous surgeons are unable to accurately predict blood thinner status of the patient based on intraoperative oozing.10 This study helped to dispel some of the myths associated with blood thinners in the setting of cutaneous surgery.
I do not advise my patients undergoing cutaneous procedures to discontinue any blood thinner used to treat a thromboembolic disorder. The following techniques may prove helpful in screening and treating cutaneous surgery patients, many of whom take one or multiple blood thinning medicines.
- Ask patient about bleeding complications from past procedures (dental extraction, teeth cleaning, invasive surgery). Inquire if they have experienced spontaneous bleeding (GI bleeding, epistaxis) or a large hematoma after relatively minor trauma. Does the patient bleed for a prolonged period after minor cuts and scratches?
- Routine preoperative INR, bleeding time, and prothrombin (PT) are not usually helpful in predicting operative and postoperative bleeding. Determine if patient has had erratic International Normalized Ratio (INR) values in the past. If values are supratherapeutic (INR>5), the risk of postoperative bleeding increases significantly.
- Inquire about other conditions that may contribute to bleeding: alcoholism, liver disease, inheritable coagulopathies (hemophilia, Von Willebrand’s disease), acne rosacea, and the use of other anticoagulants that could potentiate bleeding such as vitamin E, Ginko biloba, and nonsteroidal anti-inflammatory drugs.
- Some patients take empiric aspirin and have no obvious underlying risk of thromboembolism. Many of these patients take aspirin at the advice of friends, family or primary care provider. It is reasonable to temporarily stop such empiric aspirin intake.
- If patient has a history of severe postoperative bleeding complications, consider non-surgical modalities such as radiation.
- Meticulous homeostasis is vital in managing cutaneous surgery patients taking blood thinners. Make sure to have excellent lighting and wound retraction to assist isolating arteriole bleeding. Use a hemostat to grasp and close the vessel. Secure vessel closed with absorbable ligature. Employ electrocoagulation. If automatic implantable cardioverter defibrillator (AICD) or pacemaker is present, use bipolar forceps to stop small vessel bleeding.
- Simplify wound reconstruction. Discuss simplifying the reconstruction with the patient. Review the risks of a more noticeable scar vis-à-vis the need for continued anticoagulation. A flap, which may mobilize large amounts of skin, is probably at greater risk for hematoma and wound necrosis. Pursestring closures may work well to minimize postoperative hemorrhage. A purse-string closure does not require undermining and serves to tamponade peripheral wound bleeding. The center of the wound remains open and acts as a drain.
- Limit subcutaneous undermining. In severe cases, when patients have repeatedly soaked through the dressing whilst in the waiting room, I have closed wounds primarily without any undermining, limiting potential bleeding foci. Close the wound meticulously with multiple layers of absorbable suture to minimize dead space.
- Second intention healing is also a reasonable choice for wound management. In addition, one may apply Gelfoam® to the wound and secure a pressure dressing over the Gelfoam®. In severe cases, the surgeon can also run absorbable suture such as 5-0 Monocryl®‚ continuously around the wound edges.
- Fenestrated full thickness skin grafts with a tie-over bolster provide wound tamponade and a collagen substrate for hemostasis.
- During wound repair, consider using local anesthesia without a vasoconstrictor, such as epinephrine. Vasoconstrictors provide helpful operative bleeding reduction, prolong anethesia duration and reduce total anethetic dose. However, reactive vasodilatation in the postoperative period may predispose to hematoma because potential bleeding points, such as arterial bleeding, are not recognized at surgery.11
- Drains: in cases where refractory bleeding may continue as a generalized slow oozing, often seen in underlying coagulopathies, I will place a Jackson-Pratt or Penrose drain into the wound prior to repair and withdraw the drain after 48 hours.
- Prescribe analgesics. This not only keeps the postoperative period more restful but also reduces anxiety, pain and elevated blood pressure. High blood pressure increases intraoperative and postoperative bleeding.
- Place the wound at rest. Have patient avoid stooping, bending or lifting anything heavier than a 12oz. soda for 72 hours. Have them elevate the site and keep the area dry. Avoid any strenuous activity for 1 week. Emphasize that NSAIDs and aspirin are not to be taken for pain. Give written instructions.
Evidence continues to mount favoring blood thinner maintenance during cutaneous surgery. The risk of life-threatening thromboembolism associated with even brief cessation of blood thinners is significant. Unfortunately, primary care providers will remain unaware of the bleeding risks associated with cutaneous procedures such as Mohs excision and wound repair. The cutaneous surgeon should be aware of the various techniques and tools to reduce the risk of intraoperative and postoperative bleeding in patients taking blood thinners. Notwithstanding, bleeding complications carry far less morbidity and mortality than that of thromboembolism.