Endoscopic ultrasound-guided fine-needle aspiration of solid lesions on clopidogrel may not be a high-risk procedure for bleeding: A case series

Risk of Bleeding with Endoscopic Ultrasound-Guided Tissue Acquisition in Patients on Antithrombotic Therapy: A Systematic Review and Meta-Analysis

BACKGROUND

The present guidelines stratify endoscopic ultrasound-guided tissue acquisition (EUS-TA) as a high-bleeding risk procedure in patients on antithrombotics. However, the data regarding the same are conflicting. Therefore, this meta-analysis aimed to analyze the bleeding event rates associated with EUS-TA in patients receiving antithrombotic therapy.

METHODS

A literature search from January 2000 to August 2022 was done for studies on EUS-guided TA in patients receiving antithrombotics. The primary outcome was incidence of overall and major bleeding. Pooled event rates across studies were expressed with summative statistics.

RESULTS

A total of 12 studies were included in the meta-analysis. The pooled risk of overall bleeding and major bleeding in patients on antithrombotics was 2.0% (0.6-3.4) and 0.8% (0.0-1.6), respectively. In patients taking thienopyridine or anticoagulants, the pooled risk of overall bleeding and major bleeding was 2.4% (0.9-3.9) and 1.7% (0.4-3.1), respectively. Patients on antithrombotics had a higher odd of overall bleeding (OR 2.12, 1.20-3.83) and major bleeding (OR 3.58, 1.11-11.52) compared to controls. The odds of overall bleeding (OR 0.95, 95%CI 0.38-2.42) and major bleeding (OR 1.57, 95%CI 0.45-5.54) were comparable between patients on antithrombotics who continued and those who discontinued it preprocedural.

CONCLUSION

Despite an increase risk of bleeding with EUS-TA in patients on antithrombotics, the pooled incidence remains low. Compared to the previous guidelines stating thienopyridine use as high risk for bleeding, the present analysis showed a bleeding rate of less than 1%. Discontinuing antithrombotics prior to EUS-TA does not reduce the bleeding risk significantly, requiring strict monitoring.

Peri-procedure management of antithrombotic agents and thrombocytopenia for common procedures in oncology: Guidance from the SSC of the ISTH

Patients with cancer have an increased risk of thrombosis requiring anticoagulants and/or antiplatelet agents, and they can also encounter thrombocytopenia due to cancer itself or cancer therapies. They often undergo many procedures such as tissue or bone marrow biopsies, placement of central access lines, diagnostic or therapeutic draining procedures, lumbar puncture, and more. Management of antithrombotic agents or thrombocytopenia around the time of these procedures is highly variable. In this document, the Hemostasis and Malignancy Subcommittee of the International Society on Thrombosis and Haemostasis aims to provide useful practice guidance in the management of antithrombotic agents and thrombocytopenia around the time of common procedures in patients with cancer.

What should be known prior to performing EUS?

Direct referral of patients for EUS – instead of preprocedural consultation with the endosonographer – has become standard practice (like for other endoscopic procedures) as it is time- and cost-effective. To ensure appropriate indications and safe examinations, the endosonographer should carefully consider what information is needed before accepting the referral. This includes important clinical data regarding relevant comorbidities, the fitness of the patient to consent and undergo the procedure, and the anticoagulation status. In addition, relevant findings from other imaging methods to clarify the clinical question may be necessary. Appropriate knowledge and management of the patients’ anticoagulation and antiplatelet therapy, antibiotic prophylaxis, and sedation issues can avoid unnecessary delays and unsafe procedures. Insisting on optimal preparation, appropriate indications, and clear clinical referral questions will increase the quality of the outcomes of EUS. In this paper, important practical issues regarding EUS preparations are raised and discussed from different points of view.

Fine needle aspirates of kidneys: a promising tool for RNA sequencing in native and transplanted kidneys

Background

Transcriptome analysis is emerging as emerging as a promising tool to enhance precision of diagnosis and monitoring in solid organ transplantation. Clinical progress has however been hampered by the current reliance on samples from core needle biopsies. This proof-of-principle study examined whether fine needle aspirates, being less invasive, permit the ascertainment of the identical molecular information as core biopsies.

Methods

We collected fine needles aspirates from various needle sizes (G19, 21, 23, 25) and the corresponding core biopsies (G16 needle) of non-tumor tissue of full nephrectomy specimens from patients suffering from clear cell renal cell carcinoma (n = 11). RNA expression patterns of two gene sets (156 genes) were executed using targeted RNA sequencing in samples from fine needle vs. core needle samples. A subgroup of kidneys (n = 6) also underwent whole transcriptome RNA sequencing from core biopsies of tumor and peri-tumoral normal tissue (Tru Seq RNA Access, Illumina).

Results

Samples from all needle sizes except two G25 aspirates yielded RNA potentially suitable for sequencing of both gene sets. The mRNA expression patterns of the two gene sets were highly correlated between fine needle aspirates (G23) and corresponding (G16) core biopsies (r = 0.985 and 0.982, respectively). This close correlation was further documented by heat map, Principal Component Analyses (PCA) and whole transcription RNA sequencing. The similarity between fine neddle aspirates and core needle biopsies was additionally confirmed in the subgroup with complete RNA sequencing.

Conclusions

Fine needle biopsies yield similar genomic information to core needle biopsies. The less invasive nature of fine needle biopsies may therefore permit more frequent molecular monitoring and a more targeted use of core needle biopsies in native and especially in transplanted kidneys.

EBUS-TBNA and EUS-FNA: Risk Assessment for Patients Receiving Clopidogrel

BACKGROUND

Clopidogrel is widely used for the prevention of thrombotic vascular complications. Its primary potential toxicity is bleeding. Management of clopidogrel therapy for patients undergoing invasive procedures is an area of ongoing study. We sought to evaluate the bleeding risk for patients undergoing needle aspiration biopsy by endobronchial ultrasound (EBUS) or esophageal ultrasound (EUS) while taking clopidogrel.

METHODS

Retrospective review of sequential cases of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and esophageal ultrasound fine needle aspiration (EUS-FNA).

RESULTS

Three hundred ninety-five consecutive procedures were reviewed. Thirty-seven patients were taking clopidogrel at time of biopsy. The patients taking clopidogrel were significantly older than those in the control group. Two patients (1%) in the control group were admitted for observation, but neither was found to have a significant bleed. There were no clinically significant bleeding complications in either of the study groups.

CONCLUSIONS

It is reasonable to proceed with EBUS-TBNA or EUS-FNA when both, (1) clopidogrel cannot be stopped and, (2) an important diagnostic question is at stake.