Current Issue

The online formats of SRGS include access to What You Should Know (WYSK): commentaries on articles published recently in top medical journals. These commentaries, written by practicing surgeons and other medical experts, focus on the strengths and weaknesses of the research, as well as on the articles' contributions in advancing the field of surgery.

Below is a sample of one of the commentaries published in the current edition of WYSK.

Citation of Article Reviewed: Douketis JD, Spyropoulos AC, Murad MH, et al. Perioperative Management of Antithrombotic Therapy: An American College of Chest Physicians Clinical Practice Guideline. Chest. 2022;162(5):e207-e243. doi:10.1016/j.chest.2022.07.025

Commentary by: Vina Y. Chhaya, MD, MPH; Paige Tannhauser, MD; and Melina R. Kibbe, MD, FACS

Surgeons strive for that sweet spot of seeing enough bleeding to ensure adequate perfusion but achieving hemostasis without causing ischemia. This balance can be difficult to manage for patients taking antithrombotic and/or antiplatelet agents who require an elective procedure or surgery and can be even more challenging for emergent surgical interventions. With 42% of adults over 60 taking aspirin,¹ many patients on dual antiplatelet therapy or combination regimens, and more patients being prescribed direct oral anticoagulants (DOACs) over warfarin,² there are many factors surgeons must consider when finding the balance between bleeding and hemostasis for each surgical patient. In an attempt to provide guidance to treating physicians and standardize perioperative management of anticoagulant and antiplatelet agents, the American College of Chest Physicians published clinical practice guidelines on Perioperative Management of Antithrombotic Therapy in 2012.³ However, with the complexity that has arisen in the management of the newer anticoagulant and antiplatelet medications, including combination regimens, in the last decade, the American College of Chest Physicians recently published an update to the guidelines.⁴ This commentary aims to provide insight into the new guidelines for the practicing surgeon who manages perioperative antithrombotic therapies.

The 2022 update continues to issue guidance statements to answer questions using the same population, intervention, comparator, and outcome (PICO) format as the 2012 guidelines. After reviewing recent evidence, the expert panel issued guidance statements for the perioperative management of antithrombotic agents, including bridging therapies, and considered bleeding risk for different elective surgeries, which is similar to the 2012 guidelines. While the focus of this update is the creation of new guidance statements on the perioperative management of DOACs, including apixaban, dabigatran, edoxaban, and rivaroxaban, there are new and revised guidance statements on the management of vitamin K antagonists (VKAs) and antiplatelet agents that reflect evidence published in the past decade. The original 2012 publication contained 11 recommendations to provide an appreciation for the breadth of these updates. The 2022 updated practice guidelines contain 43 guidance statements, with 20 being new and 23 being revised or expanded statements from the 2012 guidelines.

Regarding VKA management, the 2022 guidance statements were modified to be more specific regarding interruption and/or the need for bridging therapy. For example, the guidelines now recommend that patients taking VKAs for a mechanical heart valve, atrial fibrillation, or VTE therapy no longer require bridging therapy with heparin when the VKA is interrupted for surgery. New guidance statements recommend that for patients undergoing pacemaker or ICD implantation, VKA therapy continue over interruption and heparin bridging. For patients undergoing a colonoscopy with polypectomy while taking VKA, the guidelines recommend no bridging with heparin during the period of VKA interruption. Lastly, for patients receiving low molecular weight heparin (LMWH) for bridging therapy for an elective procedure or surgery, the guidelines recommend against measuring anti-factor Xa levels to manage LMWH dosing.

Specific guidance has now been provided regarding the management of DOACs in the perioperative period. Most importantly, new guidance statements recommend that bridging therapy is not recommended for patients taking DOACs who require an elective procedure or surgery. For patients taking apixaban, edoxaban, or rivaroxaban who require an elective procedure or surgery, the guidelines recommend stopping the apixaban, edoxaban, or rivaroxaban 1-2 days before the procedure or surgery. However, for patients taking dabigatran who require an elective procedure or surgery, the guidelines recommend stopping the dabigatran 1-4 days before the procedure or surgery. Further, the guidance statements recommend resuming the DOACs >24 hours after the procedure or surgery and recommend against routine DOAC coagulation function testing to guide DOAC management.

There are also new and revised guidance statements for the following antiplatelet agents: aspirin, clopidogrel, ticagrelor, and prasugrel, as well as the combination regimen of aspirin and P2Y₁₂ inhibitors. For example, the guidance statements now recommend continuing aspirin for patients without high surgery-related bleeding risk undergoing elective non-cardiac surgery. The guidance statements for patients undergoing cardiac surgery recommend continuing aspirin but suggest interruption of P2Y₁₂ inhibitors. As with DOACs, the guidance statements recommend against routine platelet function testing to guide perioperative management. For elective non-cardiac surgeries, the guidelines recommend stopping clopidogrel five days before, ticagrelor 3-5 days before, and prasugrel seven days before the procedure or surgery. Lastly, for patients who are receiving dual therapy with aspirin and a P2Y₁₂ inhibitor who had coronary stents placed within the prior 3-12 months and now require an elective procedure or surgery, the guidance statement recommends stopping the P2Y₁₂ inhibitors before the procedure or surgery and against routine bridging therapy with a glycoprotein IIb-IIIa inhibitor, cangrelor, or LMWH. This latter scenario is certainly one that has become more commonly encountered in the past decade.

Notable strengths of this 2022 update compared to the 2012 guidance statements are the increased specificity of definitions, including grouping of thromboembolism risk based on patient factors, and alignment with the International Society on Thrombosis and Haemostasis (ISTH) to create risk-stratified groups of procedures for 30-day risk of post-procedural bleed. Overall, the updated guidance statements are given with a clearer context for patient profile and surgery type, in addition to providing new evidence supporting the perioperative management of DOACs. Compared to the 2012 guidelines, this update has guidance statements that refer to specific surgeries and procedures stratified by 30-day bleeding risk, making it more straightforward to apply the guidance statements to individual patient cases routinely. Another strength of the 2022 update is Figures 1-3, which graphically summarize guidance on the perioperative management of warfarin, DOACs, and antiplatelet agents, respectively.

The authors note limitations of these updated clinical practice guidelines and include the need to develop more specific guidance around perioperative management of DOACs before neuraxial anesthesia or nerve block procedures for patients with severe chronic kidney disease (CrCl <30 mL/min) and for patients receiving low-dose DOAC regimens or DOACs in combination regimens with aspirin. In general, each guidance statement addresses perioperative management of a single therapeutic, except statements 37-40, that address dual antiplatelet therapy of aspirin and a P2Y₁₂ inhibitor. Additionally, these guidelines are not intended for patients requiring urgent surgeries and do not cover reversal strategies for each anticoagulant or antiplatelet agent.

The American College of Chest Physicians continues to provide a valuable service in updating clinical practice guidelines around multiple topics, including perioperative management of antithrombotic therapies for elective procedures and surgeries. This update is timely, with a sustained increase in the number of patients taking DOACs and/or antiplatelet agents. It offers significantly more guidance regarding their application to surgical patients than the 2012 guidance statements. Aligning with ISTH guidance statements and stratifying risk of major bleeding as well as patient-specific peri-procedural thromboembolism risk allows ease of use with these guidance statements that clearly indicate the timing of cessation, resumption and the need for bridging therapy in specific patient cases. While limitations exist with these guidance statements, it is largely due to the need for additional research to answer important clinical questions. In the meantime, it is our responsibility as caretakers of these anticoagulated patients during the perioperative period to use these guidance statements as a framework for our patient-centered, evidence-based clinical decision-making. While we work towards more standardized perioperative management of antithrombotic therapies, the focus of the panel should now turn to reversal strategies for each therapeutic, guidance for urgent and emergent surgical cases, and segueing recommendations on resuming antithrombotic medications in the setting of a postoperative VTE.

References

1. Liu EY, Al-Sofiani ME, Yeh HC, Echouffo-Tcheugui JB, Joseph JJ, Kalyani RR. Use of Preventive Aspirin Among Older US Adults With and Without Diabetes. JAMA Netw Open. 2021;4(6):e2112210. Published 2021 Jun 1. doi:10.1001/jamanetworkopen.2021.12210
2. Troy A, Anderson TS. National Trends in Use of and Spending on Oral Anticoagulants Among US Medicare Beneficiaries From 2011 to 2019. JAMA Health Forum. 2021;2(7):e211693. Published 2021 Jul 23. doi:10.1001/jamahealthforum.2021.1693
3. Douketis JD, Spyropoulos AC, Spencer FA, et al. Perioperative management of antithrombotic therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines [published correction appears in Chest. 2012 Apr;141(4):1129]. Chest. 2012;141(2 Suppl):e326S-e350S. doi:10.1378/chest.11-2298
4. Douketis JD, Spyropoulos AC, Murad MH, et al. Perioperative Management of Antithrombotic Therapy: An American College of Chest Physicians Clinical Practice Guideline. Chest. 2022;162(5):e207-e243. doi:10.1016/j.chest.2022.07.025

The SRGS Recommended Reading List is a summary of the most pertinent articles cited in each issue; the editor has carefully selected a group of current, classic, and seminal articles for further study in certain formats of SRGS. The citations below are linked to their abstracts on PubMed, and free full texts are available where indicated.

SRGS has obtained permission from journal publishers to reprint these articles. Copying and distributing these reprints is a violation of our licensing agreement with these publishers and is strictly prohibited.

Newgard CD, Fischer PE, Gestring M, et al. National guideline for the field triage of injured patients: Recommendations of the National Expert Panel on Field Triage, 2021. J Trauma Acute Care Surg. 2022;93(2):e49-e60. doi:10.1097/TA.0000000000003627

The article details the process of developing the updated field triage guideline, the supporting evidence, and the final version of the National Guidelines for the Field Triage of Injured Patients, 2021.

Coccolini F, Stahel PF, Montori G, et al. Pelvic trauma: WSES classification and guidelines. World J Emerg Surg. 2017;12:5. Published 2017 Jan 18. doi:10.1186/s13017-017-0117-6

Complex pelvic injuries are among the most dangerous and deadly trauma-related lesions. Guidelines for managing pelvic injuries and useful maneuvers for controlling pelvic fracture bleeding and achieving early fracture stabilization are reviewed in this article.

Coccolini F, Moore EE, Kluger Y, et al. Kidney and uro-trauma: WSES-AAST guidelines. World J Emerg Surg. 2019;14:54. Published 2019 Dec 2. doi:10.1186/s13017-019-0274-x

The authors reviewed the World Society of Emergency Surgery (WSES) and the American Association for the Surgery of Trauma (AAST) kidney and urogenital trauma management guidelines. Renal and urogenital injuries occur in approximately 10-20% of abdominal trauma in adults and children. Optimal management should consider the anatomic injury, the hemodynamic status, and the associated injuries.