Risk of complications due to antithrombotic agents in cutaneous surgery: a systematic review and meta‐analysis

Abstract

Summary Background and objectives We aimed to determine the risk of complications during cutaneous surgery for the perioperative discontinuation in comparison to the continuation of antithrombotic agents and the bridging of vitamin K antagonists with heparin in comparison to their continuation. Methods We conducted a systematic review, searching three databases for eligible studies. Methods followed the Cochrane Handbook. We used RoB 2 and ROBINS‐I to assess risk of bias. The quality of evidence was judged (GRADE). Fixed‐effect meta‐analyses were performed. Results Two randomized‐controlled trials and 19 prospective cohort studies were included. It is uncertain whether, compared to its discontinuation, continuing acetylsalicylic acid (risk difference (RD) 0.004, 95 % confidence interval (CI) –0.003 to 0.019) perioperatively increases the risk of significant postoperative bleedings (SPB). Compared to its discontinuation, continuing phenprocoumon perioperatively may increase the risk of SPB (RD 0.02, 95 % CI 0.00 to 0.05). Bridging phenprocoumon with heparin perioperatively may increase the risk of SPB when compared to its continuation (RD 0.07, 95 % CI 0.01 to 0.22). No evidence was found regarding bleeding risks for direct oral anticoagulants. Conclusions No clear indications of major risks of bleedings when continuing antithrombotic agents during minor skin surgeries were identified. However, the quality of evidence was very low.

Perioperative management of antithrombotic drugs in skin surgery – A survey of dermatologists in Germany

“…A notable proportion of dermatologists bridged patients on phenprocoumon with heparin during more invasive surgeries, even though the German guideline recommends continuing phenprocoumon. Several systematic reviews suggest that bridging phenprocoumon with heparin during skin surgery might increase the risk of bleeding complications [9,16,17]. Furthermore, bridging complicates treatment as it requires restarting phenprocoumon postoperatively.…”

“…Generally, clinical practice appeared to be more heterogeneous when patients were on rivaroxaban. This might be a result of the weak evidence base guiding clinical decision making with regard to DOACs and skin surgery [9]. Furthermore, dermatologists have less experience with DOACs because these are novel drugs that were not widely prescribed before 2012 [1].…”

“…Over the following seven years, however, this share increased to more than 74 % and DOACs are now more commonly prescribed than vitamin K antagonists (e.g., phenprocoumon) [1]. To account for this new clinical landscape, the German S3 guideline was updated in 2021 [8], as was the systematic review underpinning its recommendations [9]. Among other recommendations, the new guideline recommends against the perioperative bridging of phenprocoumon with heparin.…”

Perioperatives Management von Antithrombotika in der Dermatochirurgie – Eine Umfrage unter Dermatologen in Deutschland

“…Ein beachtlicher Anteil der Dermatologen überbrückt während invasiverer Operationen Phenprocoumon mit Heparin, obwohl die deutsche Leitlinie empfiehlt, Phenprocoumon fortzuführen. Mehrere systematische Reviews legen nahe, dass die Überbrückung von Phenprocoumon mit Heparin bei Operationen an der Haut das Risiko von Blutungskomplikationen erhöhen könnte [9, 16, 17]. Außerdem erschwert diese Überbrückung das perioperative Management, da es das postoperative Wiedereinleiten der Therapie mit Phenprocoumon erforderlich macht.…”

“…In den folgenden sieben Jahren stieg dieser Anteil jedoch auf mehr als 74 % und DOAK werden nun häufiger verschrieben als Vitamin‐K‐Antagonisten wie Phenprocoumon [1]. Um dieser neuen klinischen Situation Rechnung zu tragen, wurde die deutsche S3‐Leitlinie [8] und der systematische Review [9], der ihren Empfehlungen zugrunde liegt, im Jahr 2021 aktualisiert. Unter anderem rät die neue Leitlinie von der perioperativen Überbrückung von Phenprocoumon durch Heparin ab.…”