Perioperative Aspirin Continuation in Patients Requiring Secondary Prevention Undergoing Anatomical Lung Resection: A Propensity Score‐Weighted Analysis

BACKGROUND: Managing perioperative aspirin for secondary prevention during lung resection balances major bleeding against catastrophic thromboembolism. Evidence guiding this scenario, especially for real-world strategies involving switches from other antiplatelets, remains limited for anatomical resections. METHODS: This retrospective study (2018-2025) included 625 patients undergoing anatomical lung resection. We compared aspirin continuation (Group 1, n = 94; chronic users or clopidogrel switchers) with no-therapy controls (Group 3, n = 468). Inverse probability of treatment weighting (IPW) was used to balance 16 predefined covariates. The discontinuation group (Group 2, n = 63) served as a descriptive clinical reference. Primary endpoints were major bleeding (reoperation, ≥ 4 units RBC transfusion, or death) and major adverse cardiac and cerebrovascular events (MACCEs) within 30 days. RESULTS: After IPW adjustment, all covariates achieved satisfactory balance (SMD < 0.1). Group 1 showed a potential trend toward increased major bleeding (odds ratio [OR], 5.87; 95% confidence interval [CI], 0.80-42.91; p = 0.08), but no significant difference in MACCE (OR, 1.51; 95% CI, 0.35-6.45; p = 0.58) compared to Group 3. In adjusted linear regression, aspirin was not an independent predictor of intraoperative blood loss (p = 0.25). Notably, Group 2 (discontinuation) exhibited alarmingly high rates of MACCE (7.9%) and 90-day mortality (4.8%). Analyses for rare events were statistically underpowered. CONCLUSION: Continuing aspirin showed a nonsignificant trend toward increased major bleeding, so its overall safety remains uncertain. However, the high event rates after stopping therapy highlight the significant risk of thromboembolism. Clinical judgment must carefully balance individual thrombotic benefits with potential bleeding risks.