Distinct Approaches to Perioperative Management of Anticoagulation and Antiplatelet Therapy among Providers Performing Cutaneous Surgery

July 2022 | Volume 21 | Issue 7 | 766 | Copyright © July 2022


Published online June 24, 2022

doi:10.36849/JDD.6726

Joseph Han BSa, Stephanie von Csiky-Sessoms MDa, Shayan Owji BSa, Christopher J. Yao MD, MPHb, Jonathan Ungar MDa, Nicholas Gulati MD PhDa, Ellen S. Marmur MDa

aDepartment of Dermatology, Icahn School of Medicine at Mount Sinai, New York, NY
bUniversity of Rochester School of Medicine and Dentistry, Rochester, NY

Abstract
Background: Despite increasing cross-collaboration between providers who perform cutaneous surgery, a disparity still exists in the current practices regarding perioperative management. This could lead to treatment delays, patient confusion, and increased morbidity, such as clotting, infection, and discomfort of patients.
Objective: To characterize the management practices of different providers in regards to perioperative anticoagulation and antiplatelet therapy for cutaneous surgery.
Methods and Materials: This study used an electronic survey to assess current perioperative management practices of dermatologic surgeons and plastic and reconstructive surgeons.
Results: 177 physicians (115 dermatologic surgeons and 62 plastic and reconstructive surgeons) responded to the survey. For all therapeutic agents, dermatologic surgeons were significantly more likely than their plastic and reconstructive surgery colleagues to continue all anticoagulant and antiplatelet agents perioperatively for cutaneous surgery (vitamin K antagonists, antiplatelets, LMWH, direct Xa inhibitors, direct thrombin inhibitors, NSAIDS: P<0.001; fish oil, vitamin E: P<0.01).
Conclusion: Our data highlight the significant practice gaps that exist between dermatologic surgeons and plastic and reconstructive surgeons. Reducing this disparity will facilitate improved continuity of care, especially when patients are referred from dermatologic surgeons to plastic and reconstructive surgeons for more complex repairs, and potentially reduce morbidity and mortality associated with medication discontinuation.

J Drugs Dermatol. 2022;21(7):766-772. doi:10.36849/JDD.6726

INTRODUCTION

With the number of patients on anticoagulation or antiplatelet therapy for preexisting health conditions steadily increasing, the decision to continue or discontinue these therapeutic agents is frequently encountered when performing cutaneous surgery.1 Although the practice of discontinuing anticoagulation perioperatively was accepted in the past, more recent data and literature suggest that this practice should be modified, as the relatively low risk of bleeding in cutaneous surgeries does not justify the morbidity and mortality risk associated with thrombosis.1-3

In light of more recommendations coming out to support the continuation of antithrombotic medications during cutaneous surgery, dermatologic surgeons have adjusted their practice over the years to reflect these recommendations.4-6 However, in other fields that perform cutaneous surgery on a regular basis, such as plastic and reconstructive surgery, a wide variability and lack of consensus still exist regarding the perioperative management practices of therapeutic agents.7-11 To address this issue, the American Society of Plastic Surgery (ASPS) and the American Society for Dermatologic Surgery (ASDS) co-chaired a multidisciplinary workgroup and recently published an evidence-based guideline in Dermatologic Surgery (DSS), Journal of the American Academy of Dermatology (JAAD), and Plastic and Reconstructive Surgery (PRS) to provide recommendations for physicians and other health care professionals who manage patients undergoing reconstruction after skin cancer resection (RASCR).12-14 The data collected in our study were used to support measures 2 and 3 of this recently published clinical practice guideline regarding continuation of anticoagulation, antiplatelet agents, and the associated coordination of care in patients undergoing RASCR.

The goals of our study are to describe the current practices regarding perioperative management of therapeutic agents in cutaneous surgery and to highlight the disparity that exists