Complications With New Oral Anticoagulants Dabigatran and Rivaroxaban in Cutaneous Surgery
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.