# Delayed-Onset Hematomas Following Mohs Surgery in Patients Taking a Direct Oral Anticoagulant

## TL;DR

This paper reports two cases of delayed bleeding after Mohs surgery in patients taking apixaban, emphasizing the need for clear guidance on managing anticoagulants before such procedures.

## Contribution

The paper highlights a rare complication of late-onset hematoma in patients on apixaban who did not discontinue the drug before Mohs surgery.

## Key findings

- Two patients on apixaban developed delayed-onset hematomas more than two weeks after Mohs surgery.
- The cases suggest a possible link between continued use of apixaban and late post-operative bleeding.
- Physicians should be aware of this risk and provide clear instructions to patients on anticoagulant management.

## Abstract

Direct factor Xa inhibitors or direct oral anticoagulants, like apixaban, are used to reduce the risk of stroke, deep vein thrombosis, and pulmonary embolism. It is essential that patients prescribed these drugs follow the instructions carefully. When a patient needs surgery and is on a direct oral anticoagulant, the question arises as to whether they should stop taking it before the elective surgery. There are currently no well-established guidelines instructing whether a patient should discontinue taking them before a Mohs procedure. A Mohs procedure is a precise surgery that removes skin cancers. We describe two cases of delayed-onset hematoma formation following Mohs micrographic surgery and reconstruction in patients taking direct oral anticoagulants not withheld prior to the procedure. Due to the possible uniqueness of late-onset hematoma formation greater than two weeks post-operatively in patients taking apixaban, we wanted to bring this event to the attention of other physicians. This report highlights the need to instruct patients on the possible complications of continuing the prescription and the importance of consulting the prescribing doctor before telling the patient to cease taking the drugs.