Appropriate duration to discontinue apixaban before excision of squamous cell carcinoma on the antihelix and skin grafting:
Excision of squamous cell carcinoma with skin grafting should be considered a procedure with a low to high bleeding risk, depending on extent and complexity, but generally more than minor dermatologic excision.
For low bleeding risk invasive procedures, apixaban should be discontinued at least 24 hours before the procedure. If the patient has reduced renal function (creatinine clearance 15–29 mL/min), discontinue at least 36 hours before surgery.
For high bleeding risk procedures (which may apply if extensive surgery or grafting is expected), the last dose of apixaban should be taken 3 days before surgery.
Given skin cancer excision and grafting on the antihelix may carry a bleeding risk greater than minor dermatological excision, a cautious approach would be to stop apixaban 3 days before the procedure. Restart apixaban typically 6 hours after achieving haemostasis.
Always consider patient-specific factors such as renal function, bleeding risk, and thromboembolic risk prior to interruption, and discuss with the patient accordingly.
This guidance aligns with the European Heart Rhythm Association (EHRA) and British Society of Gastroenterology (BSG)/European Society of Gastrointestinal Endoscopy (ESGE) recommendations on oral anticoagulant management around invasive procedures.
Summary: Stop apixaban 24 hours before for low bleeding risk; 36 hours if renal impairment; and 3 days before for high bleeding risk procedures like skin excision with grafting NICE CKS.