Management of Warfarin in Patients Desiring Tattoo Placement

Abstract

Objective: To provide a review of the primary literature regarding recommendations for management of chronic warfarin therapy during tattoo placement. Data Sources: PubMed and IDIS were searched (up to May 2013) using the search terms vitamin K antagonists, warfarin, anticoagulation, tattoo, tattoo placement, cutaneous procedure, and cutaneous surgery. Study Selection and Data Extraction: No trials including subjects on warfarin undergoing tattoo placement were identified. Clinical trials were included if they were published in English and included subjects on chronic warfarin therapy undergoing cutaneous procedures. Tattoo placement is similar to cutaneous procedures as skin is marked by puncturing into the dermal layer and inserting pigments, and minor bleeding is possible. Thus, recommendations of anticoagulation management for cutaneous procedures were evaluated. Data Synthesis: Eleven articles evaluating warfarin continuation around cutaneous surgery met selection criteria. Ten articles evaluated hemorrhagic complications, and 1 article evaluated thrombotic risk of perioperative anticoagulation discontinuation. In patients continuing warfarin compared to discontinuing warfarin, perioperative bleeding rate was statistically higher in 4 studies, trended higher in 3 studies, and was comparable in 3 studies. Thrombotic risk was increased when warfarin was withheld perioperatively from patients on chronic therapy. Conclusions: Trials evaluating chronic warfarin therapy in patients undergoing cutaneous surgery have conflicting recommendations for warfarin continuation through surgery. At a minimum, international normalized ratio should be evaluated prior to procedures with delay if the international normalized ratio is elevated. Thrombotic risk should be fully assessed prior to holding warfarin in patients on chronic warfarin therapy. Trials evaluating management of chronic warfarin therapy in the setting of tattoo placement are needed.