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The risk for severe complications after skin surgery does not increase in patients on aspirin or warfarin therapy. Can we say the same for clopidogrel (Plavix)? In this retrospective review of patients who underwent Mohs surgery, researchers compared rates of postsurgical complications in clopidogrel recipients and in age-, sex-, and surgical-date–matched control patients taking aspirin alone or no anticoagulants. Complications were rated as mild (bleeding for <1 hour stopped with pressure, ecchymosis, crusting, or serous oozing for <24 hours); moderate (serous oozing for >24 hours, dehiscence of <2 mm, superficial flap or graft slough); or severe (considerable intraoperative or postoperative hemorrhage, bleeding for >1 hour not stopped with pressure, acute hematoma, flap or graft necrosis).
A total of 220 clopidogrel recipients (taking clopidogrel alone or with aspirin) underwent 363 surgical procedures on 268 occasions. No complications were recorded in 86% of the clopidogrel patients, 95% of aspirin-only control patients, and 98% of no-anticoagulation control patients. Moderate complications were reported in 6% of clopidogrel patients, 1% of aspirin-only controls, and 0.2% of no-anticoagulation controls. Clopidogrel patients were 28 times likelier to have serious wound complications (3%) than no-anticoagulation controls (0%) and 6 times likelier than aspirin-only controls (0.5%). Clopidogrel-plus-aspirin recipients were 8 times likelier to have a serious wound complication (4%) than aspirin-alone patients (0.5%). Severe complications were significantly more likely with larger defects. No patients who stopped clopidogrel perioperatively had thrombotic episodes. However, one clopidogrel recipient who had stopped aspirin 2 days before surgery had a thromboembolic stroke requiring thrombolysis on postoperative day 1.
Cook-Norris RH et al. Complications of cutaneous surgery in patients taking clopidogrel-containing anticoagulation. J Am Acad Dermatol 2011 Apr 22; [e-pub ahead of print]. (http://dx.doi.org/10.1016/j.jaad.2011.02.013)
Comment
Unlike warfarin and aspirin, clopidogrel was associated with significantly increased risk for severe postoperative wound complications. Concerns about potentially life-threatening thromboembolic events militate against stopping clopidogrel in most cases. As risk for severe wound complications increases with the size of the surgical defect, a prudent approach might be to continue clopidogrel in small surgical cases and to consider holding it, after consultation with the patient's cardiologist or internist, for 5 to 7 days before surgery for large tumors. If clopidogrel is stopped, other anticoagulants should be continued or substituted in the perioperative period.