The two-layered cross technique for post-over-the-scope clip bleeding

The over-the-scope (OTS) clip is a highly effective tool for hemostasis in gastrointestinal bleeding [1] [2] [3] [4]; however, bleeding may persist despite successful placement [1] [5]. The reason is that a vessel that runs perpendicular to its closure may slip between the clip's nail and hinge, resulting in failed hemostasis ([Fig. 1]). When common hemoclips or ligature bands are used for post-OTS-clip bleeding, hemostasis is likely to be difficult due to interference of the implanted OTS clip or inadequate tissue aspiration. When a second OTS clip is used to try to stop bleeding, the occlusion of the second OTS clip tends to be in the same direction as the first OTS clip, and hemostasis may not be achieved ([Fig. 2]).