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