Can we operate a patient under anticoagulation ?

1. Oral Anticoagulants in
Outpatient Hand Surgery
1

2. • 85 yo, right hand – dominant
• Carpal Tunnel Syndrome
• Long-term oral anticoagulant
Should oral anticoagulants be stopped?
2

3. • chronic atrial fibrillation
• mechanical heart valves
• venous thromboembolism
• hypercoagulable states
Why ?
3

4. • short duration of risk
exposure
• lack of patient uniformity
• rarity of baseline adverse
events.
-> clinical judgement
Difficulties intrinsic to study design
4

5. 22 patients
carpal tunnel (n=9)
Dupuytren’s contracture (n=13)
no peri- or postoperative
bleeding complications were
identified
Elective hand surgery in patients taking
warfarin
Smit A, Hooper G. Elective hand surgery in patients taking warfarin.
J Hand Surg 2004;29B:206 –207. 5

6. 47 consecutive surgical events
INR between 1.3 and 2.9
soft tissues (75%),
skin only (9%)
bone (16%)
two patients developed minor,
bleeding-related complications
complications consistent minor
surgical procedures
Stopping warfarin therapy is
unnecessary for hand surgery
Wallace DL, Latimer MD, Belcher HJ. Stopping warfarin therapy is
unnecessary for hand surgery. J Hand Surg 2004;29B:203–205. 6

7. • Transitions = vulnerable
periods
• 45 220 warfarin group
• 11.4% had an overnight
• 7.5% of ambulatory
• 4.8% no procedure
Unintended Discontinuation of Long-term
Medication Use After Surgical Procedures
Potentially unintended discontinuation of long-term medication use after elective surgica
Bell CM, Bajcar J, Bierman AS, Li P, Mamdani MM, Urbach DR.Arch Intern Med. 2006 Dec 117

8. 2-fold increase in myocardial
infarction and death.
Perioperative antiplatelet therapy
8
Chassot PG, Delabays A, Spahn DR. Perioperative antiplatelet therapy: the case for
continuing therapy in patients at risk of myocard infarction.BrJAnaesth2007;99:316 –28

9. New anticoagulants for treatment of venous
thromboembolism
Gross PL, Weitz JI. New anticoagulants for treatment of venous
thromboembolism. Arterioscler Thromb Vasc Biol 2008;28:380 –386. 9

10. New anticoagulants for treatment of venous
thromboembolism
Gross PL, Weitz JI. New anticoagulants for treatment of venous
thromboembolism. Arterioscler Thromb Vasc Biol 2008;28:380 –386. 10

11. Patient History:
-> Why anticoag / antiplatlet
Indication:
INR 3.0 as an arbitrary ceiling
Technique:
deflation and selective electro
cautery before wound closure
Future:
challenge
Take Home Message
Wallace DL, Latimer MD, Belcher HJ. Stopping warfarin therapy is
unnecessary for hand surgery. J Hand Surg 2004;29B:203–205. 11

12. 02/01/2018 12
Merci
Camillo Theo Müller, MD
@camillomueller
12