Postendoscopic Submucosal Dissection Bleeding Risk of Periprocedural Aspirin Maintenance Therapy in Clopidogrel Users...

Aspirin maintenance is recommended during endoscopic submucosal dissection (ESD) in patients with antiplatelet therapy (APT) who are at high-thromboembolic risk. We evaluated the post-ESD bleeding risk during aspirin maintenance therapy and the timing of clopidogrel resumption.

Patients who underwent ESD for early gastric cancer or adenoma between 2011 and 2020 were included. Patients receiving APT who were at low thromboembolic risk stopped APT 7 days before ESD and resumed it 1 month after ESD (interrupted group). Patients receiving APT who were at high thromboembolic risk were maintained on aspirin (maintenance group), and pre-ESD clopidogrel users receiving one or two antiplatelet agents stopped clopidogrel 7 days before ESD and resumed it on day 15 after ESD. The primary outcome was post-ESD bleeding.

Of the 2,346 ESD cases, the overall post-ESD bleeding rate was 3.8% (90/2,346). The bleeding incidence was higher in the aspirin maintenance group (13.0%, 16/123) than in the interrupted group (2.9%, 6/209) and nonusers (3.4%, 68/2,014; p<0.001). The increase in bleeding rate was significant within 14 days, whereas it became insignificant ≥15 days after ESD. In the maintenance group, bleeding risk was not significantly increased in pre-ESD single clopidogrel users (hazard ratio [HR], 1.38; p=0.582) or dual APT users (HR, 1.18; p=0.797) compared with the single aspirin users. No bleeding events occurred after clopidogrel resumption on post-ESD day 15. Additionally, no thromboembolic events occurred in the maintenance or interrupted therapy groups.

Periprocedural aspirin maintenance increased post-ESD bleeding within 2 weeks of gastric ESD. Resuming original clopidogrel therapy 2 weeks after ESD did not increase bleeding risk in patients receiving periprocedural aspirin maintenance therapy.