Studies show that holding single antithrombotic agents perioperatively increases the risk of acute thrombotic events and does not significantly decrease the risk of bleeding complications in dermatological surgery.
In patients who are undergoing minor dermatologic procedures and are receiving VKAs, we recommend continuing VKAs around the time of the procedure (Grade 1C ACCP recommendation).
In patients who are undergoing minor dermatologic procedures and are receiving aspirin, we recommend continuing aspirin around the time of the procedure (Grade 1C ACCP recommendation). Aspirin can be stopped for 7 days prior to procedure if Aspirin is given for CAD prevention only.
In patients who are undergoing minor dermatologic procedures and are receiving clopidogrel, recommendation is to continue medication. If patients are concerned about risk of excessive bleeding, and have been on antiplatelet therapy for > 1 year, patient is asked to contact his/her Cardiologist.
Minor dermatological procedures are associated with little blood loss.
Major bleeding is rare with continuation of therapeutic anticoagulation. Bleeding risks increase when aspirin and NSAID’s are given in addition to VKAs.
Patients should be given instructions to deal with potential bleeding, and should be advised about when to seek medical attention for excessive bleeding.
General Recommendations for Pre-Procedure Warfarin Management
- Maintain INR as close to 2.0 as possible while avoiding adverse events.
- For MOHS surgery, maintain INR ≤3.0 within 10 days of the procedure.
Grines CL, Bonow RO, Casey DE Jr, et al. Prevention of premature discontinuation of dual antiplatelet therapy in patients with coronary artery stents: a science advisory from the American Heart Association, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, American College of Surgeons, and American Dental Association, with representation from the American College of Physicians. J Am Coll Cardiol 2007;49:734–9.
Lewis KG, Dufresne RG Jr. Dermatol Surg. 2008 Feb;34(2):160-4; discussion 164-5. Epub 2007 Dec 17. A meta-analysis of complications attributed to anticoagulation among patients following cutaneous surgery.
Perioperative management of anticoagulant therapy during cutaneous surgery: 2005 survey of MOHS surgeons. Dermatol Surg. 2007 Oct;33(10):1189-97.
Special thanks to Brian Jiang, MD for his expert guidance.