Safety of ultrasound-guided thoracentesis in patients receiving direct oral anticoagulants: A retrospective cohort study

BACKGROUND The safety of performing thoracentesis without interrupting direct oral anticoagulant (DOAC) therapy remains unknown. This study evaluated the safety of ultrasound-guided thoracentesis during uninterrupted DOAC treatment. METHODS In this single-center, retrospective cohort study, adult patients undergoing ultrasound-guided thoracentesis while receiving therapeutic-dose DOACs between 2019 and 2025 were evaluated. Thoracentesis was performed 2-24 hours after the last DOAC dose (or within 48 hours for patients with eGFR <60 mL/min/1.73 m²). The primary endpoint was International Society on Thrombosis and Haemostasis (ISTH)-defined major bleeding attributed to the procedure. RESULTS Overall, 137 patients were included (mean age 85.1 ± 9.2 years; 74% with eGFR <60 mL/min/1.73 m²). Apixaban was the predominant DOAC (88%). The median time from the last DOAC dose to thoracentesis was 13 hours. No major post-procedural bleeding, puncture-site hematomas, or clinically significant hemoglobin drops (>2 g/dL) occurred. Non-hemorrhagic complications included pneumothorax in 9 patients (7%). There was no procedure-related mortality. CONCLUSIONS Ultrasound-guided thoracentesis during uninterrupted DOAC therapy was not associated with major bleeding, even in elderly patients with impaired renal function. These findings suggest routine DOAC interruption before thoracentesis may be unnecessary.