Perioperative Anticoagulation in Hand Surgery: A Systematic Review

Background: Antithrombotic medications, including anticoagulants (AC) and antiplatelets (AP), are used to prevent thromboembolic events in patients with cardiovascular or hypercoagulable conditions. Current guidelines suggest stopping AC/AP therapy 3-5 days before surgery. However, recent evidence suggests that continuation of anticoagulation in certain surgeries, such as urologic and endoscopic procedures, may not increase bleeding risk and could help prevent thromboembolic events. The role of continued AC/AP therapy in hand and wrist surgery remains understudied. Objective: This systematic review aimed to synthesize the latest literature on continuing AC/AP therapy during hand and wrist surgeries and evaluate its impact on bleeding risks and thromboembolic events. Methods: A search of the PubMed and Embase databases identified 149 results, and after screening, 12 relevant studies were included in the review. Results: All 12 studies, including prospective and retrospective cohort studies and a case report, suggest that continuing AC/AP therapy during elective hand surgery generally does not significantly increase bleeding complications. The most common complication was subcutaneous hematoma, which was managed non-surgically. Major hematomas requiring reoperation were rare. A few studies noted higher bleeding complications with warfarin but they supported continuing anticoagulation if the patient's international normalized ratio was <3.5. One case study reported pulmonary embolism after discontinuing warfarin. Conclusion: Continuing AC/AP therapy in most hand surgery patients appears to be safer than interrupting anticoagulation, as the risk of thromboembolic events outweighs the potential bleeding complications. However, further research in larger cohorts and specific hand surgery types is needed for more definitive conclusions.