Can a fine needle biopsy be performed on a patient taking aspirin (acetylsalicylic acid) who is undergoing an endoscopic ultrasound?

EUS-Guided Fine Needle Biopsy on Aspirin

You can safely perform EUS-guided fine needle aspiration/biopsy while the patient continues aspirin without interruption, as this is classified as a high-risk procedure where aspirin continuation is explicitly recommended by current guidelines. 1

Risk Classification

EUS with fine needle aspiration is categorized as a high-risk bleeding procedure in both the 2018 APAGE/APSDE and 2021 BSG/ESGE guidelines. 1 Despite this high-risk classification, the management approach differs fundamentally from other antithrombotic agents:

• Aspirin monotherapy: Continue throughout the procedure 1
• P2Y12 inhibitors (clopidogrel, prasugrel, ticagrelor): Withhold 5-7 days before procedure 1
• Warfarin: Withhold 5 days before procedure 1
• DOACs: Withhold 3 days before procedure 1

Thrombotic Risk Stratification

The decision to continue aspirin is further reinforced by assessing the patient's thrombotic risk: 1

Very High Risk (ACS or PCI <6 weeks)

• Defer the procedure if possible 1

High Risk (ACS or PCI 6 weeks-6 months ago)

• Continue aspirin throughout the procedure 1
• If on dual antiplatelet therapy, withhold P2Y12 inhibitor 5 days before but maintain aspirin 1

Moderate to Low Risk (ACS/PCI >6 months ago or stable CAD)

• Continue aspirin throughout the procedure 1
• Withhold P2Y12 inhibitor 5 days before if applicable 1

Post-Procedure Management

• Resume any discontinued antithrombotic agents (excluding aspirin, which was never stopped) within 2-3 days after the procedure, depending on hemostatic adequacy 1
• Counsel patients that there is an increased risk of post-procedure hemorrhage compared to patients not on antiplatelet agents 1

Critical Pitfalls to Avoid

Never discontinue aspirin for secondary cardiovascular prevention before elective endoscopic procedures, even high-risk ones like EUS-FNA. 1, 2 The evidence shows:

• Discontinuing aspirin for secondary prevention increases risk of death or acute cardiovascular events nearly sevenfold 2
• All-cause mortality is 10 times lower in patients who continue aspirin compared to those who discontinue it 2

The only scenario to withhold aspirin is during active serious or life-threatening bleeding in an emergency setting. 1, 2 For elective procedures like scheduled EUS-FNA, aspirin should never be interrupted.

Practical Implementation

The 2021 BSG/ESGE guidelines provide the most recent evidence-based approach with a strong recommendation to continue aspirin for high-risk procedures, including EUS with fine needle sampling. 1 This represents a paradigm shift from older practices where providers routinely discontinued all antithrombotics before high-risk procedures. 3, 4

For patients on aspirin alone: Proceed with EUS-FNA without any medication adjustment 1

For patients on dual antiplatelet therapy: Coordinate with cardiology, continue aspirin, and consider withholding the P2Y12 inhibitor only if thrombotic risk permits 1