Patrick Ireland, Luca Borruso, Sascha Spencer, Robert Rosen
Aims: 38%–50% of patients undergoing cutaneous surgery are prescribed at least one anticoagulant or antiplatelet agent. With the recent emergence of Direct Oral Anticoagulants (DOACs), there is a deficit of knowledge surrounding their optimal management in the perioperative period despite their increasing prevalence. To evaluate optimal perioperative management of DOACs in patients undergoing skin and cutaneous surgeries, with respect to haemorrhagic and thromboembolic complication risk._x000D_
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Methods: Systematic review of EMBASE, Scopus and PubMed, with inclusion of studies that provided data on perioperative anticoagulation management of those prescribed a DOAC and undergoing a cutaneous procedure. Primary outcome measures were perioperative haemorrhagic and thromboembolic complications._x000D_
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Results: 7741 abstracts were identified using the search strategy listed above, with 13 articles meeting inclusion criteria. Of these, 4 were prospective cohort studies, 1 one was a case–control study, and the remaining 8 were retrospective observational studies. Two studies investigated complication risk associated with DOAC continuation in skin surgery and found an average rate of haemorrhagic complications of 1.74%. Two studies evaluated complications associated with DOAC cessation prior to skin surgery. They found a haemorrhagic complication rate of 0.25%, and thromboembolic complication rate of 0.12%. Articles that compared continuation and cessation within the same study discovered no decreased risk of bleeding with DOAC cessation prior to surgery (p = 0.93). 7 of the 13 articles compared complications in a control vs a DOAC group undergoing cutaneous procedures. Evidence was conflicting but may have suggested a small increase in bleeding risk in those anticoagulated with a DOAC._x000D_
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Conclusion: Optimal management of DOACs in the perioperative period is a contentious issue, limited by scarce and low-quality research. The risk of haemorrhagic complications with continuing DOAC appeared higher at face value, but further research is required given the limitations of the included studies. Use of validated tools such as CHADSVASC should be considered to guide perioperative management of DOACs._x000D_
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