Safety and Feasibility of Percutaneous Gastrostomy Placement in Patients on Antiplatelet Therapy

摘要

Background: Guidelines recommend the discontinuation of clopidogrel prior to gastrostomy tube placement. The aim of this study was to examine the safety and feasibility of performing radiologically inserted gastrostomy (RIG) tube placement in patients taking clopidogrel and/or aspirin.Methods: We performed an institutional review board–approved retrospective analysis of the medical records for 237 consecutive patients following RIG tube placement secondary to dysphagia from August 2017 to January 2019. Antiplatelet medications and RIG type placement techniques (push vs pull) were compared with bleeding complications. Complications were categorized based on the Society of Interventional Radiology clinical practice guidelines. Of the 237 patients with RIG tubes placed, 77 patients were on antiplatelet therapy: 55 on single antiplatelet therapy and 22 on dual antiplatelet therapy. Of the 55 patients on single antiplatelet therapy, 26 were taking clopidogrel and 29 were taking aspirin.Results: A total of 9 bleeding complications were observed. The most common complication was minimal bleeding or hematoma around the incision site (n=7). No statistically significant increase was seen in bleeding rates when comparing patients on any antiplatelet therapy regimen vs none ( P =0.15), single antiplatelet therapy vs none ( P =0.13), clopidogrel vs none ( P =0.71), or dual antiplatelet therapy vs none ( P =0.61). No significant increase in the bleeding complication rate was noted when comparing the aspirin-only regimen vs clopidogrel alone ( P =0.34).Conclusion: These findings suggest that the risk of bleeding complications is not increased in patients taking clopidogrel and/or aspirin prior to RIG tube placement. Keywords: Aspirin , clopidogrel , gastrostomy , hemorrhage , platelet aggregation inhibitors INTRODUCTIONPercutaneous gastrostomy tubes are often placed for dysphagia and risk of aspiration secondary to stroke.~(1) A 2017 update from the American Heart Association (AHA) stated that approximately 795,000 strokes occur annually in the United States,~(2) and 8% to 20% of stroke patients require either short- or long-term enteral tube feeding.~(3) Evidence shows that early tube feeding following stroke has a survival benefit.~(4) As a result, a large population of patients require gastrostomy tube placement.Current (2014) AHA and American Stroke Association (ASA) recommendations for acute management of transient ischemic attack (TIA) and ischemic stroke include the use of single antiplatelet therapy (aspirin or clopidogrel) or dual antiplatelet therapy (aspirin and clopidogrel).~(5) Dual antiplatelet therapy with aspirin and clopidogrel has been shown to reduce the risk of recurrent stroke following acute TIA and minor ischemic stroke in the first 90 days.~(6) Patients who have had strokes are routinely placed on an antiplatelet therapy regimen because of these findings.Endoscopic- and image-guided methods have been proven to be safe and effective for placement of percutaneous gastrostomy tubes.~(7) The current (2011) standard of practice for gastrostomy tube placement is based on multidisciplinary practical guidelines from the Society of Interventional Radiology (SIR) and the American Gastroenterological Association Institute.~(8) These guidelines include recommendations from both the American Society for Gastrointestinal Endoscopy (ASGE) and the SIR on radiologically inserted gastrostomy (RIG) tube placement for patients prescribed antiplatelet therapy. The ASGE considers RIG tube placement a high-risk procedure and recommends withholding clopidogrel for 7 days and replacing it with aspirin. The SIR considers RIG tube placement a moderate risk for hemorrhage and recommends withholding clopidogrel for 5 days but does not recommend withholding aspirin.While studies have evaluated the safety of performing endoscopic gastrostomy tube placement in patients taking clopidogrel or dual antiplatelet therapy, as of 2020, little had been published in the radiologic literature evaluating the safety and feasibility of gastrostomy tube placement in the angiography suite in patients taking single or dual antiplatelet therapy with clopidogrel.The purpose of this study was to evaluate the safety and feasibility of placing RIG tubes in patients taking single or dual antiplatelet therapy of aspirin and/or clopidogrel.METHODSAn institutional review board (IRB)–approved, Health Insurance Portability and Accountability Act–compliant retrospective review was conducted for all patients who had a RIG tube placed between August 1, 2017 and January 18, 2019 at a single institution. Informed consent was waived by the IRB. The Epic electronic medical record (Epic Systems Inc) was queried during the study dates for all patients who presented to interventional radiology for RIG tube placement. Inpatient and outpatient populations were included. Antiplatelet therapy regimen and RIG tube type (push vs pull) were collected.Patients who received