EUS-guided versus percutaneous spleen biopsy: Comparative safety and diagnostic performance in a tertiary center

Background and Objectives: Percutaneous biopsy is the traditional method for diagnosing splenic lesions but carries a risk of hemorrhage due to the organ’s rich vascularity. EUS-guided biopsy has emerged as a minimally invasive alternative that may reduce bleeding risk. This study compared the safety and diagnostic performance of EUS-guided and percutaneous spleen biopsies. Methods: We retrospectively analyzed 91 patients who underwent splenic biopsy at a tertiary center between 2015 and 2023 (EUS, n = 63; percutaneous, n = 28). The primary outcome was the occurrence of procedure-related adverse events graded by the Adverse Events in Gastrointestinal Endoscopy (AGREE) classification. Secondary outcomes included tissue adequacy and diagnostic performance. Statistical analyses used Fisher’s and Boschloo tests, Firth-penalized logistic regression, and propensity-score overlap weighting to adjust for confounders. Results: Clinically relevant adverse events (AGREE grade ≥2) occurred among 0% of EUS-guided and 10.7% of percutaneous biopsies (absolute risk difference: −10.7%, 95% confidence interval: −21.1% to −0.3%; P = 0.029). After adjustment, EUS-guided biopsy remained independently associated with fewer major adverse events (adjusted odds ratio: 0.09, 95% confidence interval: 0.00 to 0.78; P = 0.047). Diagnostic sensitivity was comparable between EUS and percutaneous biopsy (86.4% vs. 93.3%; P = 0.74), with 100% specificity in both. Conclusion: EUS-guided spleen biopsy was associated with a lower rate of clinically relevant adverse events, maintaining comparable diagnostic accuracy. These findings suggest that EUS-guided biopsy is a safer and equally effective alternative for splenic tissue acquisition, warranting validation in larger prospective studies.