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Endobronchial Biopsies on Aspirin and Prasugrel
CLINICAL SPOTLIGHT
Heart, Lung and Circulation (2015) 24, e68–e70 1443-9506/04/$36.00 http://dx.doi.org/10.1016/j.hlc.2015.01.009
Endobronchial Biopsies on Aspirin and Prasugrel Kassem Harris, MD, FCCP a,b*, Jad Kebbe, MD b a
Roswell Park Cancer Institute, Department of Medicine, Interventional Pulmonary section, Buffalo, NY, USA Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University at Buffalo, State University of New York, NY, USA
b
Received 8 December 2014; received in revised form 17 December 2014; accepted 19 January 2015; online published-ahead-of-print 2 February 2015
Patients are generally required to stop antiplatelet therapy prior to elective invasive procedures. Some patients receive dual antiplatelet therapy for recent vascular procedures such as drug-eluting coronary stenting, and early discontinuation of antiplatelet agents could lead to a significant risk of stent thrombosis. Most bronchoscopic procedures are performed on patients using Aspirin but not on those using Clopidogrel or Prasugrel. In this report, we describe a unique case of a patient with a recent placement of drug-eluting stents, who required endobronchial biopsies for evaluation of lung cancer recurrence. The procedure was performed successfully and safely with no complications. Keywords
Aspirin Prasugrel Endobronchial biopsy Bleeding Bronchoscopy
Introduction Antiplatelet therapy with aspirin and clopidogrel or clopidogrel alone has been shown to increase the risk of bleeding after transbronchial biopsies [1]. In a small retrospective case series, dual antiplatelet therapy was safely continued in patients undergoing endobronchial ultrasound guided transbronchial aspiration [2]. Most diagnostic and therapeutic bronchoscopies are performed while patients are receiving aspirin with no increased risk of bleeding [3]. There is no data however on performing endobronchial biopsies in patients on dual antiplatelet therapy. In this report, we describe the bronchoscopic techniques to safely perform endobronchial biopsies on patients using dual antiplatelet therapy.
Case Description A 68 year-old man was diagnosed with early stage squamous cell lung cancer, and underwent a right lower lobectomy with bronchus margin positive for carcinoma in situ. The patient declined chemotherapy and was hence enrolled in
high-risk lung cancer surveillance program with chest CT scan and autofluorescence bronchoscopy. The one-year bronchoscopy and narrow band imaging showed significant inflammation and oedema at the level of the stump (Figure 1). Given his history of cancer with positive margin lobectomy, and high suspicion of cancer recurrence, we decided to proceed with endobronchial biopsies of the stump lesion. The patient had two coronary stents placed three months earlier and was receiving aspirin and prasugrel. The stents were both drug-eluting (Promus PREMIERTM) and were placed in the proximal and mid right coronary artery. After an explicit benefit and risk discussion with the patient and his cardiologist, we performed endobronchial biopsies without discontinuing the dual antiplatelet therapy. The procedure was performed under general anaesthesia after several haemostasis tools were made available. The airways developed patches of bruises as clear secretions were suctioned from the right upper lobe and the left bronchial tree, which was indicative of increased airway friability. The right lower lobe stump was flushed with 60 ml of iced saline followed by obtaining two endobronchial biopsies. This was
*Corresponding author at: Roswell Park Cancer Institute, Elm & Carlton streets, Buffalo NY, 14623. Tel.: +(716) 845-3851; fax: +(716) 845-8232, Email: [email protected] © 2015 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier Inc. All rights reserved.
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Biopsy on dual antiplatelet therapy
Figure 1 A: Bronchoscopic view of right lower lobe stump showing the area of oedema and erythaema (arrow). B: NBI view showing the highly abnormal area at the stump site (arrow). C: Bronchoscopic view of the endobronchial biopsy using the miniforceps. D: APC of the right lower lobe stump after endobronchial biopsies.
repeated until we obtained a total of eight biopsies using a 1.2 mm miniforceps (reusable FB-56D-1 by Olympus). Afterwards, argon plasma coagulation (APC) was used to prevent delayed bronchial bleeding. The procedure was performed successfully with no complications and the patient was discharged home. Pathologic examination revealed chronic inflammation and oedema with no evidence of malignancy.
Discussion Aspirin therapy has been widely used for various medical conditions such as acute and chronic pain, prevention and treatment of vascular diseases, and treatment of rheumatologic disorders. In addition to its anti-inflammatory effect, aspirin has been the antiplatelet prototype for decades. Clopidogrel and prasugrel are newer agents with exclusive antiplatelet activity that irreversibly bind to P2Y12 adenosine diphosphate receptors, inhibiting platelet activation and aggregation for the lifespan of the platelet. Compared to clopidogrel, prasugrel is more potent with quicker onset of action [4]. Patients are usually instructed to stop clopidogrel or prasugrel for five to seven days prior to invasive procedures. Diagnostic and therapeutic bronchoscopies have long been performed on aspirin with no reported increased risk of bleeding complications [3]. A recent retrospective review of 12 patients showed that endobronchial ultrasound guided transbronchial aspiration was safely performed on dual antiplatelet therapy with aspirin and clopidogrel [2]. In a prospective
study of transbronchial biopsies performed on aspirin and clopidogrel versus clopidogrel alone, the risk of significant bleeding was very high at 100% and 89% respectively [1]. All patients in the aspirin and clopidogrel group developed moderate to severe bleeding but no fatalities or surgical interventions were reported. However, endobronchial biopsy in patients receiving dual antiplatelet therapy is not well described in the literature. In many patients with recent coronary artery stenting, early discontinuation of dual antiplatelet therapy prior to an elective invasive procedure exhibits a high risk of life-threatening stent thrombosis. In our case, given the findings on surveillance and the high risk of recurrence due to prior positive lobectomy margins, it was determined that endobronchial biopsies were necessary. However, a high risk of bleeding was present, paralleled with a high risk of stent thrombosis given the recent placement, should prasugrel be discontinued. Nonetheless, the endobronchial biopsies were safely performed on dual antiplatelet therapy after informed consent. There was no bleeding at the biopsy site and we determined that the use of iced saline immediately prior to obtaining the endobronchial biopsies induced temporary capillary constriction and prevented bleeding. Furthermore, the application of APC to the biopsy site prevented delayed bleeding after resolution of the icing effect. Endobronchial biopsies on dual antiplatelet therapy may be performed using other techniques. Pre-injection of the biopsy site with epinephrine can prevent bleeding after endobronchial biopsies. Another method would be the use of direct probe or spray cryotherapy to freeze the biopsy site, which would probably prevent bleeding after endobronchial biopsies. Moreover, cauterising the area surrounding the biopsy site is another possible technique that may hinder capillary supply to the biopsy site, thus preventing bleeding. The most crucial step of this procedure is to prepare for possible bleeding complications. Our patient had had a type and screen and the blood bank was made aware of the possible need for platelet transfusion. Bronchial blocking and balloon catheters were at the bedside during the procedure. The procedure and the possible bleeding complications had been thoroughly discussed with the patient, and the endoscopy and anaesthesia teams.
Conclusion We thus hypothesise that endobronchial biopsies can be safely undertaken while a patient is receiving dual antiplatelet therapy with aspirin and prasugrel under certain circumstances, after detailed counselling and preparation for possible bleeding complications.
Disclosures Authors don’t have any personal or financial disclosures. No funding was received for this research.
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References [1] Ernst A, Eberhardt R, Wahidi M, Becker HD, Herth FJ. Effect of routine clopidogrel use on bleeding complications after transbronchial biopsy in humans. Chest 2006;129(3):734–7. [2] Stather DR, MacEachern P, Chee A, Tremblay A. Safety of endobronchial ultrasound-guided transbronchial needle aspiration for patients taking
K. Harris, J. Kebbe
clopidogrel: a report of 12 consecutive cases. Respiration 2012;83(4): 330–4. [3] Herth FJ, Becker HD, Ernst A. Aspirin does not increase bleeding complications after transbronchial biopsy. Chest 2002;122(4):1461–4. [4] Reinhart KM, White CM, Baker WL. Prasugrel: a critical comparison with clopidogrel. Pharmacotherapy 2009;29(12):1441–51.
Heart, Lung and Circulation (2015) 24, e68–e70 1443-9506/04/$36.00 http://dx.doi.org/10.1016/j.hlc.2015.01.009
Endobronchial Biopsies on Aspirin and Prasugrel Kassem Harris, MD, FCCP a,b*, Jad Kebbe, MD b a
Roswell Park Cancer Institute, Department of Medicine, Interventional Pulmonary section, Buffalo, NY, USA Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University at Buffalo, State University of New York, NY, USA
b
Received 8 December 2014; received in revised form 17 December 2014; accepted 19 January 2015; online published-ahead-of-print 2 February 2015
Patients are generally required to stop antiplatelet therapy prior to elective invasive procedures. Some patients receive dual antiplatelet therapy for recent vascular procedures such as drug-eluting coronary stenting, and early discontinuation of antiplatelet agents could lead to a significant risk of stent thrombosis. Most bronchoscopic procedures are performed on patients using Aspirin but not on those using Clopidogrel or Prasugrel. In this report, we describe a unique case of a patient with a recent placement of drug-eluting stents, who required endobronchial biopsies for evaluation of lung cancer recurrence. The procedure was performed successfully and safely with no complications. Keywords
Aspirin Prasugrel Endobronchial biopsy Bleeding Bronchoscopy
Introduction Antiplatelet therapy with aspirin and clopidogrel or clopidogrel alone has been shown to increase the risk of bleeding after transbronchial biopsies [1]. In a small retrospective case series, dual antiplatelet therapy was safely continued in patients undergoing endobronchial ultrasound guided transbronchial aspiration [2]. Most diagnostic and therapeutic bronchoscopies are performed while patients are receiving aspirin with no increased risk of bleeding [3]. There is no data however on performing endobronchial biopsies in patients on dual antiplatelet therapy. In this report, we describe the bronchoscopic techniques to safely perform endobronchial biopsies on patients using dual antiplatelet therapy.
Case Description A 68 year-old man was diagnosed with early stage squamous cell lung cancer, and underwent a right lower lobectomy with bronchus margin positive for carcinoma in situ. The patient declined chemotherapy and was hence enrolled in
high-risk lung cancer surveillance program with chest CT scan and autofluorescence bronchoscopy. The one-year bronchoscopy and narrow band imaging showed significant inflammation and oedema at the level of the stump (Figure 1). Given his history of cancer with positive margin lobectomy, and high suspicion of cancer recurrence, we decided to proceed with endobronchial biopsies of the stump lesion. The patient had two coronary stents placed three months earlier and was receiving aspirin and prasugrel. The stents were both drug-eluting (Promus PREMIERTM) and were placed in the proximal and mid right coronary artery. After an explicit benefit and risk discussion with the patient and his cardiologist, we performed endobronchial biopsies without discontinuing the dual antiplatelet therapy. The procedure was performed under general anaesthesia after several haemostasis tools were made available. The airways developed patches of bruises as clear secretions were suctioned from the right upper lobe and the left bronchial tree, which was indicative of increased airway friability. The right lower lobe stump was flushed with 60 ml of iced saline followed by obtaining two endobronchial biopsies. This was
*Corresponding author at: Roswell Park Cancer Institute, Elm & Carlton streets, Buffalo NY, 14623. Tel.: +(716) 845-3851; fax: +(716) 845-8232, Email: [email protected] © 2015 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier Inc. All rights reserved.
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Biopsy on dual antiplatelet therapy
Figure 1 A: Bronchoscopic view of right lower lobe stump showing the area of oedema and erythaema (arrow). B: NBI view showing the highly abnormal area at the stump site (arrow). C: Bronchoscopic view of the endobronchial biopsy using the miniforceps. D: APC of the right lower lobe stump after endobronchial biopsies.
repeated until we obtained a total of eight biopsies using a 1.2 mm miniforceps (reusable FB-56D-1 by Olympus). Afterwards, argon plasma coagulation (APC) was used to prevent delayed bronchial bleeding. The procedure was performed successfully with no complications and the patient was discharged home. Pathologic examination revealed chronic inflammation and oedema with no evidence of malignancy.
Discussion Aspirin therapy has been widely used for various medical conditions such as acute and chronic pain, prevention and treatment of vascular diseases, and treatment of rheumatologic disorders. In addition to its anti-inflammatory effect, aspirin has been the antiplatelet prototype for decades. Clopidogrel and prasugrel are newer agents with exclusive antiplatelet activity that irreversibly bind to P2Y12 adenosine diphosphate receptors, inhibiting platelet activation and aggregation for the lifespan of the platelet. Compared to clopidogrel, prasugrel is more potent with quicker onset of action [4]. Patients are usually instructed to stop clopidogrel or prasugrel for five to seven days prior to invasive procedures. Diagnostic and therapeutic bronchoscopies have long been performed on aspirin with no reported increased risk of bleeding complications [3]. A recent retrospective review of 12 patients showed that endobronchial ultrasound guided transbronchial aspiration was safely performed on dual antiplatelet therapy with aspirin and clopidogrel [2]. In a prospective
study of transbronchial biopsies performed on aspirin and clopidogrel versus clopidogrel alone, the risk of significant bleeding was very high at 100% and 89% respectively [1]. All patients in the aspirin and clopidogrel group developed moderate to severe bleeding but no fatalities or surgical interventions were reported. However, endobronchial biopsy in patients receiving dual antiplatelet therapy is not well described in the literature. In many patients with recent coronary artery stenting, early discontinuation of dual antiplatelet therapy prior to an elective invasive procedure exhibits a high risk of life-threatening stent thrombosis. In our case, given the findings on surveillance and the high risk of recurrence due to prior positive lobectomy margins, it was determined that endobronchial biopsies were necessary. However, a high risk of bleeding was present, paralleled with a high risk of stent thrombosis given the recent placement, should prasugrel be discontinued. Nonetheless, the endobronchial biopsies were safely performed on dual antiplatelet therapy after informed consent. There was no bleeding at the biopsy site and we determined that the use of iced saline immediately prior to obtaining the endobronchial biopsies induced temporary capillary constriction and prevented bleeding. Furthermore, the application of APC to the biopsy site prevented delayed bleeding after resolution of the icing effect. Endobronchial biopsies on dual antiplatelet therapy may be performed using other techniques. Pre-injection of the biopsy site with epinephrine can prevent bleeding after endobronchial biopsies. Another method would be the use of direct probe or spray cryotherapy to freeze the biopsy site, which would probably prevent bleeding after endobronchial biopsies. Moreover, cauterising the area surrounding the biopsy site is another possible technique that may hinder capillary supply to the biopsy site, thus preventing bleeding. The most crucial step of this procedure is to prepare for possible bleeding complications. Our patient had had a type and screen and the blood bank was made aware of the possible need for platelet transfusion. Bronchial blocking and balloon catheters were at the bedside during the procedure. The procedure and the possible bleeding complications had been thoroughly discussed with the patient, and the endoscopy and anaesthesia teams.
Conclusion We thus hypothesise that endobronchial biopsies can be safely undertaken while a patient is receiving dual antiplatelet therapy with aspirin and prasugrel under certain circumstances, after detailed counselling and preparation for possible bleeding complications.
Disclosures Authors don’t have any personal or financial disclosures. No funding was received for this research.
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References [1] Ernst A, Eberhardt R, Wahidi M, Becker HD, Herth FJ. Effect of routine clopidogrel use on bleeding complications after transbronchial biopsy in humans. Chest 2006;129(3):734–7. [2] Stather DR, MacEachern P, Chee A, Tremblay A. Safety of endobronchial ultrasound-guided transbronchial needle aspiration for patients taking
K. Harris, J. Kebbe
clopidogrel: a report of 12 consecutive cases. Respiration 2012;83(4): 330–4. [3] Herth FJ, Becker HD, Ernst A. Aspirin does not increase bleeding complications after transbronchial biopsy. Chest 2002;122(4):1461–4. [4] Reinhart KM, White CM, Baker WL. Prasugrel: a critical comparison with clopidogrel. Pharmacotherapy 2009;29(12):1441–51.