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

Anticoagulant and antiplatelet (AC/AP) use is common and practice surrounding AC/AP continuation or cessation peri-operatively for minor cutaneous surgery lacks evidence-based consensus. To determine the risks of haemorrhagic and thromboembolic complications associated with the continuation or cessation of AC/AP therapy in minor cutaneous surgery. A systematic literature search was conducted using PubMed, MEDLINE, Embase and CENTRAL, to identify all articles involving the use of AC/AP in patients undergoing minor cutaneous surgery, including skin grafts and local flaps. Eligible studies were randomised control trials, prospective studies and retrospective studies in the English language. Studies investigating free-flap repairs, oculoplastic surgery and hand surgery were excluded. 30 studies included data from over 14,000 patients, of which more than 5000 took regular AC/AP therapy. Thromboembolic events were rare but carry high morbidity and even mortality, and in these studies three events were associated with cessation of AC/AP. There was no increase in haemorrhagic complications in patients taking aspirin monotherapy, but evidence is conflicting regarding warfarin and clopidogrel monotherapy, which shows a small increase in rate of bleeding complications. However, no increase in wound dehiscence, graft failure, wound infection or cosmetic outcome was seen. Too few studies investigated DOAC use to draw reliable conclusions. Data are sparse in comparing multiple versus single AC/AP regimens. Use of skin grafts or local flaps may have a greater complication rate than direct closure in patients on one or more AC/AP, but evidence is limited. A case-by-case risk assessment is warranted in all patients but where possible, clinicians should prioritise meticulous haemostasis over cessation of agents.