The Management of Antithrombotic Medication in Skin Surgery

Abstract

Approximately one in four patients undergoing dermatologic surgery takes an antithrombotic medication. When approaching the management of antithrombotic agents, procedural dermatologists must balance surgical outcomes, bleeding risks, and cardiovascular protection. Continuing antithrombotics during surgery increases the risk hemorrhage, but discontinuation of these agents may increase the risk of thrombotic events. Despite increasing evidence for continuation of antithrombotics during dermatologic surgery, few official guidelines exist, and clinicians have been slow to integrate new evidence into clinical practice. A study in 2007 reported that more than 40% of dermatologic surgeons sometimes discontinue warfarin for surgery. This article reviews antithrombotic agents in the United States and summarize perioperative management recommendations of antithrombotic agents in skin surgery. A review of the literature was performed focused on antithrombotic medications commercially available in the United States, including the two newest agents, dabigatran and rivaroxaban. Although there are concerns regarding bleeding, there are no reports of life-threatening hemorrhage from continued antithrombotic therapy in dermatologic surgery. Furthermore, potentially fatal cardiovascular events after cessation of medically indicated antithrombotic medications are increasingly recognized, leading to the growing acceptance that the risk of stopping most antithrombotics may outweigh the risks of bleeding incurred by continuing antithrombotic therapy.