Association between antithrombotic drug management and bleeding during high-risk endoscopic procedures: A multi-center retrospective observational study

Background & Aims: Optimal management of antithrombotic drugs (ATDs) is essential to minimize bleeding during high-risk endoscopic procedures. This study aimed to investigate peri-procedural ATD strategies to reduce 30-day post-procedural bleeding. Methods: We performed a multicenter, retrospective cohort study on high-risk endoscopic procedures. The primary outcome was 30-day bleeding requiring endoscopic hemostasis. We categorized the peri-procedure management of ATDs into continuation, discontinuation, and replacement. We evaluated the risk differences in 30-day bleeding among ATD management groups, as compared to patients who did not take ATDs (nonusers). Results: High-risk upper-GI procedures included 1365 esophageal ESDs, 788 elective EVLs, 5391 gastric ESDs, and 2562 PEGs; lower-GI procedures included 23326 colonic polypectomy/EMRs and 2769 colonic ESDs. ATDs management included aspirin continuation (n=818) and discontinuation (n=62); thienopyridine discontinuation (n=188) and replacement (n=97); warfarin continuation (n=97) and discontinuation (n=20); DOAC discontinuation (n=487). Thirty-day bleeding occurred in 5.89% of upper-GI and 1.22% of lower-GI procedures. Bleeding risk differed according to antithrombotic drug management. In upper-GI procedures, numerically higher bleeding rates were observed in some antithrombotic management groups, particularly aspirin continuation and thienopyridine discontinuation during gastric ESD, compared with nonusers; however, the absolute risk differences were within 10%. In contrast, bleeding risk differences in lower-GI procedures were smaller overall and within 5%. Conclusions: This multicenter study describes differential bleeding risk patterns across high-risk endoscopic procedures among patients receiving antithrombotic therapy.