Continuing Clopidogrel Increases Intraprocedural Bleeding and Clip Use After Cold Snare Polypectomy, but Not Delayed Bleeding
Douglas K. Rex, MD, MASGE, reviewing Ket SN, et al. Endosc Int Open 2022 Mar 30.
Guidelines have often recommended the continuation of clopidogrel for diagnostic colonoscopy but discontinuation for polypectomy, which is impractical because polypectomy rates are so high during diagnostic colonoscopy.
The current study included patients who were already receiving clopidogrel alone (n=66) or dual therapy with clopidogrel plus aspirin (n=41) and randomized them to either continue clopidogrel alone or discontinue clopidogrel but continue or substitute aspirin for 7 days before and 2 days after colonoscopy. All polyps were removed by cold snare polypectomy and were ≤10 mm. Of the removed polyps, 134 were removed in the clopidogrel-continuation arm versus 142 in the aspirin-only arm. According to the results, 86% of all patients included in the study had a polyp removed, with a median of 2 polyps removed per patient.
Clip use was recommended in the trial if intraprocedural bleeding persisted for more than 2 minutes. Intraprocedural bleeding requiring clips occurred in 11 of 49 clopidogrel-continuation patients and 2 of 43 taking aspirin alone (P=.02). Minor postprocedural bleeding was seen in the aspirin-only group more often than in the clopidogrel-continuation group (6/43 vs 1/49; P=.03). One nonfatal cardiac ischemic event occurred in each arm.
The trial was stopped early because of inadequate patient accrual.
COMMENTFirst, these results indicate that clopidogrel continuation does not increase the risk of delayed hemorrhage after cold snaring, but endoscopists should remember that several studies have reported the increased risk of delayed hemorrhage with clopidogrel after hot snaring. Second, clopidogrel does produce an increase in intraprocedural bleeding after cold snaring, somewhat arbitrarily defined in the study as duration >2 minutes. This bleeding is associated with the cost and inconvenience of clip application, and using this definition is also associated with the cost and inconvenience of watching the site bleed for 2 minutes. It is possible that other techniques could stop the bleeding and avert the need for clip application, including water-jet filling the submucosa, temporarily regrasping the site with the open snare, or applying direct pressure to the bleeding site with the endoscope tip to tamponade the bleeding vessel.
Note to readers: At the time we reviewed this paper, its publisher noted that it was not in final form and that subsequent changes might be made.
CITATION(S)
Ket SN, Hewett DG, Kheir AO, et al. Cold snare polypectomy of colorectal polyps ≤10mm on clopidogrel: an Australian and New Zealand randomised controlled trial. Endosc Int Open 2022 Mar 30. (Epub ahead of print) (https://doi.org/10.1055/a-1813-1019)
