S3 guidelines for the management of anticoagulation in cutaneous surgery

Background: An increasing number of patients are being treated with anticoagulants and platelet inhibitors. Whenever surgical procedures of the skin are required, questions arise regarding the perioperative management of anticoagulation. Methods: Development of S3 guidelines following the requirements of the Association of Scientific Medical Societies, systematic literature search and analysis, use of GRADE methodology, structured consensus conference using a nominal group process. Results: During cutaneous surgery, treatment with acetylsalicylic acid (ASA) should be continued if medically necessary. In procedures with a higher risk of bleeding and a positive bleeding history, INR should be determined preoperatively. Surgical procedures of the skin with a higher risk of bleeding should not be performed if the INR is above therapeutic range. Bridging from vitamin K antagonists (VKA) to heparin should not be performed just because of the surgery of the skin. As to direct-acting oral anticoagulants, the last dose should be taken 24 h preoperatively. Conclusions: The recommendations issued by the German guidelines group are mostly in line with recommendations provided by other guidelines. The American "Chest-Guideline" recommends continuing VKAs and acetylsalicylic acid during minor dermatologic procedures. In their guidelines, the German College of General Practitioners and Family Physicians considers an INR of 2 to be adequate in surgical procedures on the skin.