What is the risk of hemorrhage during percutaneous transhepatic biliary drainage (PTBD) in a patient taking Ascard (aspirin)?

Risk of Hemorrhage During PTBD in Patients Taking Ascard (Aspirin)

The risk of hemorrhage during percutaneous transhepatic biliary drainage (PTBD) in patients taking aspirin is elevated but manageable, with significant bleeding occurring in approximately 10-13% of cases, though severe bleeding remains relatively uncommon at around 3%.

Understanding the Bleeding Risk

The available evidence specifically addressing PTBD procedures shows that hemorrhagic adverse events occur in 13.5% of patients undergoing PTBD, with severe cases representing only 3.0% of procedures 1. This baseline risk applies to the general PTBD population, but aspirin use adds complexity to the risk assessment.

Key Risk Factors for PTBD-Related Hemorrhage

Based on prospective multicenter data, the following factors significantly increase bleeding risk during PTBD 1:

• Vascular punctures during the procedure (odds ratio 4.1)
• Fatty liver or cirrhosis (odds ratio 3.7)
• Number of capsular punctures (odds ratio 2.5)
• Intrahepatic tumor obstruction (Bismuth ≥2; odds ratio 2.4)

Importantly, antiplatelet drug use (including aspirin) was NOT independently associated with hemorrhagic adverse events in multivariate analysis 1. However, this finding requires careful interpretation in the context of other biliary procedures.

Evidence from Related Biliary Procedures

While direct PTBD-specific data on aspirin is limited, evidence from similar percutaneous transhepatic procedures provides important context:

Percutaneous Transhepatic Gallbladder Interventions

A 2023 study examining bleeding risk in patients receiving antithrombotic therapy during percutaneous transhepatic gallbladder procedures found 2:

• Single antithrombotic drug continuation (which would include aspirin monotherapy): No significantly increased bleeding risk
• Multiple antithrombotic drugs continued: Significantly higher risk of bleeding (P = 0.006)
• Overall significant bleeding rate: 10.3%
• Severe bleeding rate: 3.1%

Endoscopic Biliary Sphincterotomy Data

The 2021 BSG/ESGE guidelines provide relevant comparative data for biliary interventions 3:

• In a retrospective study of 762 patients undergoing endoscopic sphincterotomy, those who continued antiplatelet therapy had a 16.3% bleeding rate (with 14.3% delayed bleeding) compared to 6.0% in those who discontinued for <7 days 3
• Another study of 191 patients showed no statistically significant increase in hemorrhage in the aspirin group (50 patients) 3
• The evidence suggests aspirin continuation during biliary procedures carries risk but is not uniformly prohibitive

Clinical Decision Framework

Risk Stratification

PTBD should be classified as a moderate-to-high bleeding risk procedure when considering antiplatelet management. The French perioperative guidelines classify procedures based on whether they are feasible on aspirin monotherapy 4:

• High-risk procedures: Not feasible even on aspirin monotherapy (includes certain liver surgeries)
• Moderate-risk procedures: Feasible on aspirin alone (majority of invasive procedures)

PTBD falls into a gray zone requiring individualized assessment based on:

1. Patient-specific factors: Presence of cirrhosis, fatty liver, coagulopathy status, hemoglobin levels
2. Procedural factors: Anticipated number of punctures, presence of intrahepatic tumors, operator experience
3. Thrombotic risk: Indication for aspirin (secondary prevention of cardiovascular disease carries high thrombotic risk if discontinued)

Practical Management Approach

For patients on aspirin monotherapy undergoing PTBD:

1. Assess thrombotic risk first: If aspirin is for secondary prevention of cardiovascular disease, discontinuation carries significant risk of thrombotic events 5, 6

2. Optimize correctable factors 1:

   • Correct any coagulopathy (patients with corrected coagulopathies had fewer hemorrhagic events; odds ratio -5.5)
   • Optimize hemoglobin levels preoperatively
   • Address prealbumin levels if low 7

3. Consider continuation of aspirin if:

   • High cardiovascular thrombotic risk
   • No cirrhosis or fatty liver
   • Normal coagulation parameters
   • Experienced operator performing procedure

4. Consider discontinuation if:

   • Multiple high-risk features present (cirrhosis, anticipated multiple punctures, intrahepatic tumors)
   • Low cardiovascular risk
   • Can be bridged safely

5. If discontinuing aspirin: Stop 5-7 days before procedure to allow platelet function recovery 4

Critical Caveats

• The 2022 prospective study found antiplatelet use was NOT an independent risk factor for hemorrhagic events in PTBD 1, which differs from assumptions based on other procedures
• Multiple antithrombotic agents significantly increase risk - avoid if possible 2
• Left-sided approach increases hepatic arterial injury risk (odds ratio 1.93) 8
• Correcting coagulopathy is protective and should always be done regardless of aspirin status 1

The decision to continue or discontinue aspirin must weigh the 10-16% bleeding risk against the thrombotic risk of aspirin cessation in patients with established cardiovascular disease, where recent evidence shows no long-term cardiovascular benefit but persistent bleeding risk with aspirin use 5.