Complications With New Oral Anticoagulants Dabigatran and Rivaroxaban in Cutaneous Surgery

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We read with great interest the Chang and colleagues1 article. While we agree with their conclusions, we wish to highlight our experience with rivaroxaban in particular, recognizing that no other study has been published regarding its safety in cutaneous surgery and guidance for the cutaneous surgeon is lacking. There is some urgency in formulating a consensus regarding this and other newer oral antithrombotic agents because of the current medicolegal climate and the proliferation of cardiac stenting. We performed a retrospective review of our Mohs-microscopic-surgery patient database from October 2012 to October 2015 (Figure 1). During this time, 918 Mohs surgeries were performed, including the 15 unique patients undergoing a total of 18 surgical procedures while on rivaroxaban. Three hematomas were witnessed during this period and all developed in patients on rivaroxaban. Somewhat predictably, the hematomas occurred on the neck in 1 case and in the setting of large random flaps in the other 2 cases. The hematomas were uncomplicated, but bleeding could only be controlled with the cessation of the rivaroxaban for 4 days postoperatively in 2 of the cases. It is important to point out from our data that the performance of random skin grafts was highly correlated with hematoma development. There were no perioperative cardiovascular events associated with the surgeries.
Based on our data and the experience of Chang, we have issued general guidance to our staff (who frequently answer patient queries regarding anticoagulant cessation) to routinely continue all anticoagulants in all patients as the safest course of action, unless instructed otherwise by the physician. Patients are counseled in preoperative planning that the closures will be carefully planned to minimize the risk of bleeding, wide undermining will be avoided whenever possible, simple repairs with second-intention healing will be completed if appropriate, and flap closures will be avoided unless a compelling reason exists to use this closure. We believe that rivaroxaban does increase the risk of bleeding complications after Mohs surgery. We continue to recommend that patients remain on their prescribed anticoagulants in general. If a large repair or large flap with extensive undermining is anticipated, coordination with the patient's anticoagulant prescribing provider can be undertaken to further define risks of its cessation in that patient's individual circumstance. We await the day that an antidote to Factor Xa inhibitors will translate to clinical usefulness during Mohs surgery.2 One such newly described agent, andexanet, has demonstrated prompt utility within minutes of infusion and may be precisely what is needed in bleeding emergencies. (ANNEXA-4 phase 3b-4 study.) (ClinicalTrials.gov number NCT02329327.

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