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Warfarin and Clopidogrel Are More Likely Than Aspirin to Cause Perioperative Bleeding

But office surgery is still safe in patients on anticoagulants and antithrombotics.

Bordeaux and colleagues prospectively studied differences in bleeding complication rates in 1911 recipients of antiplatelet and anticoagulant therapy who underwent Mohs or excisional surgery.

Overall rates of bleeding complications, including perioperative complications (<24 hours after surgery), postoperative complications (>24 hours after surgery), and hematoma formation, were extremely low at 0.89%. Warfarin (Coumadin) and clopidogrel (Plavix) had statistically significant associations with bleeding complications; complications were 40 times more likely in patients receiving both drugs simultaneously than in all others. Aspirin was not associated with bleeding complications. None of the observed bleeding complications affected long-term patient management or led to a serious adverse event. In secondary findings, vitamin E was not associated with bleeding, and infection rates were higher at anatomic sites other than the face in anticoagulant recipients.

Comment: The strengths of this study were its large sample size, its prospective design, and its inclusion of eight surgeons; the study may be the first to detect a statistically significant risk for bleeding after cutaneous surgery in patients on warfarin, clopidogrel, or both, but not on aspirin. The results apparently debunk the conventional surgical wisdom that aspirin is the most problematic anticoagulant. Regardless, the main message is that outpatient excisional skin surgery in patients receiving anticoagulants and antithrombotics is extremely safe. Bleeding is uncommon or rare, even in high-risk patients and, when it does occur, causes no serious outcomes. When anticoagulants are continued presurgery, the risk and impact of bleeding complications are small; when anticoagulants are not continued, the risk for serious problems like stroke, myocardial infarction, and clotted cardiac valves is greater. Thus, most dermatologic surgeons do not recommend routine cessation of anticoagulant medications before cutaneous surgery. Of course, every case must be evaluated on its specific merits. Surgeons should be prepared for some bleeding issues when treating warfarin and clopidogrel recipients, especially those using both. Availability of suction or a surgical first assistant may be helpful. It seems appropriate to discuss with patients before surgery the risk for bleeding, its likely minimal impact on their health, and the importance of nonetheless continuing anticoagulant medications to protect their overall cardiovascular status.

— Murad Alam, MD, MSCI

Published in Journal Watch Dermatology August 19, 2011

Citation(s):

Bordeaux JS et al. Prospective evaluation of dermatologic surgery complications including patients on multiple antiplatelet and anticoagulant medications. J Am Acad Dermatol 2011 Sep; 65:576.

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Review and add to remarks on this article

• good
  Mark E Baldwin, 23 Aug 2011 12:30 PM EST
  Specialty: Occupational Medicine
  good topic, concise and to the point

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