Outcomes of EUS-FNA in patients receiving antithrombotic therapy

Abstract

Background and study aims To investigate bleeding risk and thromboembolic risk in patients receiving antithrombotic therapy who underwent endoscopic ultrasound-guided fine-needls aspiration (EUS-FNA).

Patients and methods A single-center retrospective study of 908 consecutive patients undergoing EUS-FNA for pancreatic and non-pancreatic lesions patients between March 2013 and March 2017 was performed. Antithrombotic management was classified into three groups: continuous, discontinuation, and heparin replacement.

Results A total of 114 patients (12.6 %) were on antithrombotic drugs and 794 (84.6 %) were not. There were six cases of significant bleeding (0.7 %) four in the antithrombotic group (0.4 %) and two (0.2 %) in the non-antithrombotic group, (odds ratio, 9.59; 95 % confidence interval, 2.12 – 43.1; P = 0.006). Of the four cases in the antithrombotic group, two were on continuous treatment, one was on discontinuation treatment and one was on heparin replacement. All cases of non-significant bleeding occurred in the non-antithrombotic group (3 peri-tumoral hematomas, 1 submucosal hematoma, and 1 intraluminal bleed). The sole thromboembolic event (0.9 %) was a cerebral infarction in the antithrombotic group in a patient on thienopyridine who switched to aspirin before the procedure.

Conclusions There was a slight increase in risk of bleeding in patients receiving antithrombotic therapy especially postoperative bleeding; however, there were no cases of severe bleeding was seen and only one case of cerebral infarction which occurred in a high-risk thromboembolic patients. We concluded that EUS-FNA in a safe procedure for patients on antithrombotics, even when antithrombotic therapy is not discontinued during EUS-FNA.

• Reference

• 1 Hamada T, Yasunaga H, Nakai Y. et al. Severe bleeding and perforation are rare complications of endoscopic ultrasound-guided fine needle aspiration for pancreatic masses: an analysis of 3,090 patients from 212 hospitals. Gut Liver 2014; 8: 215-218
• 2 Wang KX, Ben QW, Jin ZD. et al. Assessment of morbidity and mortality associated with EUS-guided FNA: a systematic review. Gastrointest Endosc 2011; 73: 283-290
• 3 Varadarajulu S, Eloubeidi MA. Frequency and significance of acute intracystic hemorrhage during EUS-FNA of cystic lesions of the pancreas. Gastrointest Endosc 2004; 60: 631-635
• 4 Oprea AD, Noto CJ, Halaszynski TM. Risk stratification, perioperative and periprocedural management of the patient receiving anticoagulant therapy. J Clin Anesth 2016; 34: 586-599
• 5 Kien-Fong VuC, Chang F, Doig L. et al. A prospective control study of the safety and cellular yield of EUS-guided FNA or Trucut biopsy in patients taking aspirin, nonsteroidal anti-inflammatory drugs, or prophylactic low molecular weight heparin. Gastrointest Endosc 2006; 63: 808-813
• 6 Inoue T, Okumura F, Sano H. et al. Bleeding risk of endoscopic ultrasound-guided fine-needle aspiration in patients undergoing antithrombotic therapy. Dig Endosc 2016;
• 7 Burger W, Chemnitius JM, Kneissl GD. et al. Low-dose aspirin for secondary cardiovascular prevention - cardiovascular risks after its perioperative withdrawal versus bleeding risks with its continuation - review and meta-analysis. J Intern Med 2005; 257: 399-414
• 8 Boustière C, Veitch A, Vanbiervliet G. et al. Endoscopy and antiplatelet agents. European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2011; 43: 445-461
• 9 Committee ASoP . Anderson MA, Ben-Menachem T. et al. Management of antithrombotic agents for endoscopic procedures. Gastrointest Endosc 2009; 70: 1060-1070
• 10 Veitch AM, Baglin TP, Gershlick AH. et al. Guidelines for the management of anticoagulant and antiplatelet therapy in patients undergoing endoscopic procedures. Gut 2008; 57: 1322
• 11 Fujimoto K, Fujishiro M, Katou M. et al. Guidelines for gastroenterological endoscopy in patients undergoing antithrombotic treatment. Gastroenterol Endosc 2012; 54: 2075-2102 (in Japanese)
• 12 Fujimoto K, Fujishiro M, Kato M. et al. Guidelines for gastroenterological endoscopy in patients undergoing antithrombotic treatment. Dig Endosc 2014; 26: 1-14
• 13 Matsumura T, Arai M, Maruoka D. et al. Risk factors for early and delayed post-operative bleeding after endoscopic submucosal dissection of gastric neoplasms, including patients with continued use of antithrombotic agents. BMC Gastroenterology 2014; 14: 172
• 14 Cotton PB, Eisen GM, Aabakken L. et al. A lexicon for endoscopic adverse events: report of an ASGE workshop. Gastrointest Endosc 2010; 71: 446-454
• 15 Affi A, Vazquez-Sequeiros E, Norton ID. et al. Acute extraluminal hemorrhage associated with EUS-guided fine needle aspiration: Frequency and clinical significance. Gastrointestinal Endoscopy 2001; 53: 221-225
• 16 Baron TH, Kamath PS, McBane RD. Management of antithrombotic therapy in patients undergoing invasive procedures. N Engl J Med 2013; 368: 2113-2124
• 17 Kowalewski M, Suwalski P, Raffa GM. et al. Meta-analysis of uninterrupted as compared to interrupted oral anticoagulation with or without bridging in patients undergoing coronary angiography with or without percutaneous coronary intervention. Int J Cardiol 2016; 223: 186-194
• 18 Koh R, Hirasawa K, Yahara S. et al. Antithrombotic drugs are risk factors for delayed postoperative bleeding after endoscopic submucosal dissection for gastric neoplasms. Gastrointest Endosc 2013; 78: 476-483