Antiplatelet Therapy in Patients Undergoing EBUS-TBNA: Risk vs Benefit

Abstract

PURPOSE: Endobronchial ultrasound with transbronchial needle aspiration (EBUS-TBNA) has improved the ease with which practitioners can obtain mediastinum tissue samples. However, evidence-based studies are limited regarding best management of dual antiplatelet agents (DAPT) aspirin and clopidogrel, or clopidogrel alone in patients who undergo this procedure. One 2006 study recommended discontinuation of clopidogrel prior to transbronchial biopsy after documenting increased bleeding severity in patients taking clopidogrel. However, a recent retrospective review of 12 patients, suggested that EBUS-TBNA can be performed safely by experienced operators in patients taking clopidogrel. Our study further evaluates adverse bleeding events following EBUS-TBNA in patients exposed to DAPT, clopidogrel only, or aspirin (ASA) alone 5 days prior to the procedure versus patients unexposed to anti-platelet medications. METHODS: Retrospective chart review was conducted on patients aged 18 or older who underwent EBUS-TBNA between January 1, 2009 and December 31, 2014 at our institution. Patients were excluded from analysis if taking anti-platelet medications other than clopidogrel and/or aspirin, if using therapeutic anticoagulation, if had history of bleeding or clotting disorder, active disseminated intravascular coagulation, or platelet count <80,000. Adverse bleeding events were defined as any one of the following: immediate bleeding requiring procedural interruption and/or topical intervention, red blood cell transfusion requirement within 24 hours of procedure, hemoglobin drop $ 2 grams, or readmission within 48 hours of procedure for hemoptysis or anemia. Data included demographics, comorbidities, and pre/post procedure CBC. Data was analyzed via one-way ANOVA and chi-square tests. RESULTS: Of 476 patients, 67 were excluded. Of the remaining patients: DAPT n¼23; clopidogrel n¼13; ASA n¼103; unexposed n¼270. Overall bleeding events were low, occurring in 2.9% of all patients: DAPT n¼2 (8.7%); clopidogrel n¼1 (7.7%); ASA n¼1 (<1%); unexposed n¼8 (2.9%), p ¼ 0.164. No immediate bleeding events were recorded for patients taking DAPT or clopidogrel alone, but these patients were more likely to experience hemoglobin drop > 2g: DAPT n¼1 (4.3%); clopidogrel n¼1 (7.7%); ASA n¼0 (0.0%); unexposed n¼2 (0.7%), p ¼ 0.019. Patients taking DAPT were more likely to be readmitted in 48 hours: DAPT n¼1 (4.3%); clopidogrel n¼0 (0.0%); ASA n¼0 (0.0%); unexposed n¼1 (0.4%), p ¼ 0.053. CONCLUSIONS: Similar rates of bleeding suggest that discontinuation of DAPT or clopidogrel may not be necessary prior to EBUS-TBNA. However, the absolute number of bleeding complications was low in both exposed and unexposed patients and definitive recommendations require a larger patient population to achieve adequate statistical power. CLINICAL IMPLICATIONS: Clinicians should weigh individual risks and benefits when deciding to discontinue DPTA or clopidogrel before EBUS-TBNA.

EBUS-TBNA on Patients Receiving Antiplatelet Therapy

“…In total, 8.7% of patients on dual antiplatelet therapy and 7.7% on clopidogrel had bleeding events, compared with a rate of only 2.9% for patients not on antiplatelet therapy. 10 The lack of statistical significance in this study may be attributed to its small sample size.…”

Management of oral antiplatelet agents and anticoagulation therapy before bronchoscopy

“…Overall bleeding events were low, occurring in 2.9% of all patients, 8.7% for patients on both aspirin and clopidogrel, 7.7% for clopidogrel alone, <1 % for aspirin alone and 2.9% for patients not on any antiplatelet therapy. The difference was not statistically significant (P=0.164) (8). Another series reported twelve cases of EBUS-TBNA procedures performed on patients taking clopidogrel.…”

Effect of Routine Clopidogrel Use on Bleeding Complications After Endobronchial Ultrasound-guided Fine Needle Aspiration

“…12 In addition, others reported on the safety of thoracotomy when performed on patients taking clopidogrel. 12,16,17 Further, Stather et al 13 in a retrospective single center review of 12 cases, reported no significant bleeding with similar gauge needles. In the latter study, patients were followed for 30 days postprocedure.…”