136 – Should anticoagulants be withheld prior to performing hand and wrist surgeries?
Geert Meermans, Amy C. Lu, Patricia Fogarty Mack, Christopher M. Jones.
Response/Recommendation: Antiplatelet and anticoagulant medication do not need to be discontinued in patients undergoing hand and wrist surgeries, especially in patients at high-risk of venous thromboembolism (VTE) and those undergoing carpal tunnel surgery.
Recommendation: Moderate.
Rationale: Anticoagulant and antiplatelet medications are commonly used to prevent primary or recurrent thrombotic events1. The most common side effect of anticoagulant or antiplatelet treatment is a tendency to bleed with resultant bruising, hematoma formation, and potential wound healing problems.
The management of anticoagulation in patients undergoing surgical procedures is challenging, because interrupting anticoagulation for a procedure transiently increases the risk of thromboembolism. At the same time, surgery and invasive procedures have associated bleeding risks that are increased by the anticoagulant(s) administered. Therefore, a decision must be made based weighing the risk of bleeding and the risk of thromboembolic events2.
A recent review demonstrated that either continuation or discontinuation of antiplatelet therapy before non-cardiac surgery may make little or no difference to mortality, bleeding requiring surgical intervention or transfusion, and ischemic events3. Moreover, a recent meta-analysis concluded that interrupting anticoagulation in patients requiring invasive procedures did not result in increased thromboembolic events and protected against major bleeding4. However, neither of these studies included upper limb surgery.
Hand and wrist surgeries are generally considered low bleeding risk procedures, however, it is unclear where specific hand and wrist interventions fall along the spectrum in terms of bleeding risk5,6. Therefore, wide variability in daily practice continues to exist with regards to the management of antiplatelet and anticoagulant medication in patients undergoing hand or wrist surgery7.
Nine studies8–16 and one meta-analysis17 examined the effect of antiplatelet and anticoagulant medications on complication rate in hand or wrist surgery. Of these nine studies, four10,12,13,16 were retrospective and five8,9,11,14,15 were prospective cohort studies. In five studies8,10–13 the effect of antiplatelets was investigated, while four studies9,14–16 looked at anticoagulants or an elevated international normalized ratio ( INR). Surgery was performed without a tourniquet in one study10, with tourniquet deflation and haemostasis before skin closure in one study12, and according to the surgeon’s preference in two studies8,9. The timing of tourniquet deflation in relation to skin closure was not specified in the remaining studies.
Stone et al.,17 found in their meta-analysis that hand and wrist surgery on anticoagulated patients did not affect the risk of reoperation for bleeding. Continuing anticoagulation did not affect the risk of a postoperative haematoma or bruising within 14 days, although the quality of the evidence was very low. Similarly, antiplatelets did not affect the risk of reoperation for postoperative bleeding nor the risk of haematoma or bruising, although the quality of the evidence was low.
There are several limitations. Firstly, the studies only included surgery distal to the wrist and the vast majority were carpal tunnel releases so it remains to be seen whether these findings can be extrapolated to other procedures. Secondly, the type of anesthesia was not specified in all studies8,9,15,16 and it is unclear if there is an advantage using general anesthesia, a neuraxial block11,14 or local anesthesia12,14 exclusively or with epinephrine10,13 with regards to postoperative bleeding complications. Thirdly, wide-awake local anesthesia no tourniquet (WALANT) in minor hand surgery procedures has been shown to decrease tourniquet-associated discomfort and improve the perioperative patient experience18, but only one study did not use a tourniquet10. Given these findings regarding bleeding complications, definitive recommendations cannot be made whether operating with or without tourniquet should be advocated.
In orthopaedic surgery, anticoagulants are usually stopped due to the bleeding risk, and there continues to be a paucity of data regarding hand or wrist surgery. The meta-analysis by Stone et al.,17 suggests that antiplatelet and anticoagulant medication can be safely continued for patients undergoing carpal tunnel surgery and those at high-risk of VTE. For other elective hand or wrist surgery, the evidence is less convincing, however, unless there is a strong perceived need to interrupt medication, then anticoagulation should probably be continued perioperatively.
References:
1. Barlow BT, Hannon MT, Waldron JE. Preoperative Management of Antithrombotics in Arthroplasty. J Am Acad Orthop Surg. 2019;27(23):878-886. doi:10.5435/JAAOS-D-17-00827
2. Spyropoulos AC, Brohi K, Caprini J, et al. Scientific and Standardization Committee Communication: Guidance document on the periprocedural management of patients on chronic oral anticoagulant therapy: Recommendations for standardized reporting of procedural/surgical bleed risk and patient-specific thromboembolic risk. J Thromb Haemost. 2019;17(11):1966-1972. doi:10.1111/jth.14598
3. Lewis SR, Pritchard MW, Schofield-Robinson OJ, Alderson P, Smith AF. Continuation versus discontinuation of antiplatelet therapy for bleeding and ischaemic events in adults undergoing non-cardiac surgery. Cochrane Database Syst Rev. 2018;7:CD012584. doi:10.1002/14651858.CD012584.pub2
4. Hovaguimian F, Köppel S, Spahn DR. Safety of Anticoagulation Interruption in Patients Undergoing Surgery or Invasive Procedures: A Systematic Review and Meta-analyses of Randomized Controlled Trials and Non-randomized Studies. World J Surg. 2017;41(10):2444-2456. doi:10.1007/s00268-017-4072-x
5. Doherty JU, Gluckman TJ, Hucker WJ, et al. 2017 ACC Expert Consensus Decision Pathway for Periprocedural Management of Anticoagulation in Patients With Nonvalvular Atrial Fibrillation: A Report of the American College of Cardiology Clinical Expert Consensus Document Task Force. J Am Coll Cardiol. 2017;69(7):871-898. doi:10.1016/j.jacc.2016.11.024
6. Douketis JD, Spyropoulos AC, Kaatz S, et al. Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation. N Engl J Med. 2015;373(9):823-833. doi:10.1056/NEJMoa1501035
7. Twoon M, Hallam M-J. Anticoagulation therapy and hand surgery: Do we worry too much? Indian J Plast Surg. 2015;48(3):326-327. doi:10.4103/0970-0358.173144
8. Bogunovic L, Gelberman RH, Goldfarb CA, Boyer MI, Calfee RP. The impact of antiplatelet medication on hand and wrist surgery. J Hand Surg Am. 2013;38(6):1063-1070. doi:10.1016/j.jhsa.2013.03.034
9. Bogunovic L, Gelberman RH, Goldfarb CA, Boyer MI, Calfee RP. The Impact of Uninterrupted Warfarin on Hand and Wrist Surgery. J Hand Surg Am. 2015;40(11):2133-2140. doi:10.1016/j.jhsa.2015.07.037
10. Boogaarts HD, Verbeek ALM, Bartels RHMA. Surgery for carpal tunnel syndrome under antiplatelet therapy. Clin Neurol Neurosurg. 2010;112(9):791-793. doi:10.1016/j.clineuro.2010.07.002
11. Brunetti S, Petri GJ, Lucchina S, Garavaglia G, Fusetti C. Should aspirin be stopped before carpal tunnel surgery? A prospective study. World J Orthop. 2013;4(4):299-302. doi:10.5312/wjo.v4.i4.299
12. Jivan S, Southern S, Majumder S. Re: the effects of aspirin in patients undergoing carpal tunnel decompression. J Hand Surg Eur Vol. 2008;33(6):813-814. doi:10.1177/1753193408094707
13. Kaltenborn A, Frey-Wille S, Hoffmann S, et al. The Risk of Complications after Carpal Tunnel Release in Patients Taking Acetylsalicylic Acid as Platelet Inhibition: A Multicenter Propensity Score-Matched Study. Plast Reconstr Surg. 2020;145(2):360e-367e. doi:10.1097/PRS.0000000000006465
14. Naito K, Lequint T, Zemirline A, Gouzou S, Facca S, Liverneaux P. Should we stop oral anticoagulants in the surgical treatment of carpal tunnel syndrome? Hand (N Y). 2012;7(3):267-270. doi:10.1007/s11552-012-9425-1
15. Nandoe Tewarie RDS, Bartels RHMA. The perioperative use of oral anticoagulants during surgical procedures for carpal tunnel syndrome. A preliminary study. Acta Neurochir (Wien). 2010;152(7):1211-1213. doi:10.1007/s00701-010-0603-z
16. Zimmerman RM, Paryavi E, Zimmerman NB, Means KR. Complications after hand surgery in patients with a raised International Normalized Ratio. J Hand Surg Eur Vol. 2017;42(7):742-746. doi:10.1177/1753193417711652
17. Stone MJ, Wilks DJ, Wade RG. Hand and wrist surgery on anticoagulants and antiplatelets: A systematic review and meta-analysis. J Plast Reconstr Aesthet Surg. 2020;73(8):1413-1423. doi:10.1016/j.bjps.2020.05.017
18. Kurtzman JS, Etcheson JI, Koehler SM. Wide-awake Local Anesthesia with No Tourniquet: An Updated Review. Plast Reconstr Surg Glob Open. 2021;9(3):e3507. doi:10.1097/GOX.0000000000003507