Warfarin Institute of America
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WHEN PATIENTS TAKING WARFARIN NEED SKIN SURGERY
Kovich O, Otley CC. Thrombotic complications related to discontinuing warfarin and aspirin therapy perioperatively for cutaneous operation. J Am Acad Dermatol 2003;48:233-7.
Another article reported on 68 patients who had skin surgery at a hospital in the United Kingdom over a period of 30 months. The patients had INRs ranging from 1.1 to 3.4 with a median of 2.5. None of the patients had excessive intraoperative, or postoperative bleeding or hematoma. The authors conclude that warfarin should be continued for skin surgery. They do recommend doing an INR check within 24 hours before surgery and proceeding if the INR is below 3.5.
J. Alcalay from the Mohs Surgery Unit at Assuta Medical Center in Tel Aviv, Israel reported on 16 patients who underwent Mohs or excisional surgery while continuing their warfarin therapy. The report states that intraoperative bleeding was easily controlled and postoperative bleeding was not recorded in any of the patients. All wounds healed without any complication, including full-thickness grafts. The author concludes that Coumadin treatment should be continued in patients undergoing cutaneous surgery to decrease the risk of thromboembolic events. Dermatol Surg 2001;27:756-758.
Ah-Weng et al (Br J Dermatol. 2003;149:386-9) report on 68 patients who had 85 skin procedures done while anticoagulated at a median INR of 2.5. There was no excessive bleeding or bruising during or after the procedures. They recommend an INR be done within 24 hours before the procedure to assure that it is not above the therapeutic range.
ALSO
Kovich, O.
Thrombotic complications related to discontinuation of warfarin and
aspirin therapy perioperatively for cutaneous operation. J m Acad Dermatol
2003 Feb;48 (2 Pt 2):233-237 (any librarian can look this up)
The authors are from Mayo Clinic in Rochester, Minnesota. They found (in a
poll of 168 doctors) that when warfarin was withheld before skin surgery
the risk of a clot doubled from 1 in 13,000 to 1 in 6,000. The clotting
events were strokes, heart attacks, TIAs, DVT, PE, 1 clot in the eye
leading to blindness and 3 deaths.
There was no increase in severe bleeding complications.
The authors call this, "a compelling argument to keep patients on
medically necessary blood thinners during cutaneous operation."
Otley (Mayo Clin Proc.2003;78:1392-1396) says, " Excisional cutaneous surgery is performed commonly in patients who take medically necessary aspirin or warfarin... recent data suggest that the risk of severe hemorrhagic complications is not increased if these medications are continued. Brief perioperative discontinuation does not lower this already minimal hemorrhagic risk. Furthermore, life-threatening thromboembolic complications have been related temporally to perioperative discontinuation of both aspirin and warfarin. In light of the absence of benefit and the presence of risks associated with discontinuation of warfarin and aspirin perioperatively during excisional cutaneous surgery, continuation of these medications is recommended in most situations." What it boils down to is, if your doctor wants you to stop these medications ask what there is about your history that suggests that you will be at higher risk if you stop them than if you do not. If the answer is, "I always do it this way," then you might want to find another doctor because yours is not keeping up to date.
I have not been able to find any study that showed any group of people who had skin surgery while their INR was in the therapeutic range that had any significant amount of bleeding. I know that individual cases could be cited but they are less compelling than group studies.
A physician friend of mine underwent removal of a melanoma while his INR was in the 3 range. Since he had a mechanical valve, he did not want to discontinue warfarin. He said that he had a 5 inch long incision that the dermatologist reported did not bleed any more than someone who was not on warfarin.
My personal experience. I take an aspirin daily. I do not take warfarin. My wife discovered a brown spot that appeared to be growing on the top of my bald head. I saw my physician in the hospital the next day and showed it to him. He asked me to come to his office that afternoon and he would cut it out. Obviously I had not planned this and did not stop my aspirin. The microscopic examination of what he removed showed "melanoma in situ with intact margins". This means that it appears that it was all removed. The recommendation for this is to have a second incision taking about 1/4 inch (0.5 cm) all the way around the previous area so that there is certainty that all was removed. The second procedure was scheduled with a dermatologist. Knowing when it was going to be done, I stopped the aspirin about 3 days before the procedure. During the procedure, the dermatologist remarked that it sure was bleeding a lot. I remarked that I had stopped the aspirin three days previously. His reply was that I should have stopped it long before that. Well, when I got off the table, I looked at the amount of blood on the paper covering the pillow and I could see no difference from what I had done about one month before. After both procedures I went right back to work. There was no excessive loss of blood either time.
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