A 70-year-old man presents for Mohs micrographic surgery (MMS) to remove a 2.3-cm squamous cell carcinoma from the right temple. The procedure is expected to require multiple stages and a complex linear repair. His medical history includes atrial fibrillation and peripheral arterial disease. He is taking warfarin and aspirin 81 mg daily. His INR is checked two days prior to surgery and is 2.7. He has had no prior bleeding complications from dermatologic procedures. He expresses concern about bruising but wants to avoid any risk of stroke or clotting. What is the most appropriate management of his antithrombotic medications for this surgical procedure?

A. Discontinue both aspirin and warfarin 5 days prior to surgery and bridge with low molecular weight heparin

B. Hold aspirin but continue warfarin

C. Hold warfarin and continue aspirin; resume warfarin 2 days postoperatively

D. Continue both aspirin and warfarin without interruption

E. Delay surgery until patient is transitioned off warfarin and onto a direct oral anticoagulant

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