A 44-year-old female with stage IV rectal cancer, bilateral nephrostomy tubes, and a history of DVTs on Eliquis presented with shortness of breath. A CTA showed new large bilateral pleural effusions and ascites, likely malignant. The patient would benefit from a therapeutic thoracentesis to drain the pleural fluid. Thoracentesis is generally safe in patients taking novel oral anticoagulants like Eliquis, with a low risk of major bleeding complications. Individualized management of anticoagulation is important to minimize risks. Validated bleeding risk scores can help guide anticoagulation management for percutaneous procedures.

1. Assessment of Bleeding Risk
in Procedures
Varsha John, MS

2. Case
44 y/o F w PMHx stage IV rectal carcinoma s/p radiation and loop sigmoid colostomy and bilateral
nephrostomy tubes placed presently and Hx of bilateral DVTs on Eliquis presented to ED from SNF after
discharge from outside hospital same day for treatment of bacteremia.
● CTA C/A/P new large bilateral pleural effusion and ascites, likely malignant
● Patient reported shortness of breath
○ Would benefit from therapeutic thoracentesis

3. Pleural Effusion
● Pleural effusions are diagnosed in about 1.5 million
individuals in the United States annually
● Among the causes, pleural infection, heart failure, and
malignancy are the most common.
● Can cause a variety of symptoms, including shortness of
breath, chest pain, and cough.
● Management of pleural effusion depends on the underlying
cause and may include treating the underlying condition,
draining the fluid from the pleural space, or both

4. Pleural Effusion
● Accumulation of fluid in the pleural space, which is the space
between the lungs and the chest wall. Some of the most common
causes of pleural effusion include:
○ Increased hydrostatic pressure in the pleural space due to
heart failure, cirrhosis, or kidney failure
○ Decreased oncotic pressure in the pleural space due to
hypoalbuminemia or protein-losing disorders
○ Increased permeability of the pleural capillaries due to
infections, inflammation, or malignancies
○ Impaired lymphatic drainage due to lymphatic obstruction
or trauma
○ Direct injury to the pleural space due to trauma or surgery

5. Thoracentesis
Thoracentesis is a medical procedure used to remove fluid from the pleural space. The procedure involves inserting a needle or
catheter through the chest wall and into the pleural space to drain the fluid.
Diagnostic purposes: Diagnose the cause of pleural effusion, which is the accumulation of fluid in the pleural space. The fluid can
be analyzed for signs of infection, inflammation, cancer, or other underlying conditions.
Symptomatic pleural effusion: Relieve symptoms associated with pleural effusion, such as shortness of breath, chest pain, or
cough.
Therapeutic purposes: Remove large volumes of fluid from the pleural space in patients with symptomatic pleural effusion or to
prevent respiratory compromise.
Monitoring purposes: monitor the response to treatment in patients with pleural effusion or to detect recurrent effusions.
Preoperative evaluation: Before certain surgeries, such as lung resection or thoracotomy, to evaluate the presence of pleural
effusion and reduce the risk of complications.

6. Medication Considerations
Anticoagulants: targeting specific clotting factors in the blood to prevent the formation of blood clots
○ Vitamin K antagonists (e.g. warfarin)
○ Heparins (e.g. unfractionated heparin, low molecular weight heparin)
○ Direct thrombin inhibitors (e.g. dabigatran)
○ Factor Xa inhibitors (e.g. rivaroxaban, apixaban, edoxaban)
○ Antiplatelet agents (e.g. aspirin, clopidogrel, ticagrelor)

7. The study aimed to evaluate the safety of ultrasound-guided thoracentesis in patients on novel oral
anticoagulants (NOACs) and clopidogrel.
The study included 159 patients who underwent ultrasound-guided thoracentesis while on NOACs or clopidogrel
between 2015 and 2018.
● none of the patients experienced major bleeding or required blood transfusions
● one patient developed a small hematoma, and another patient developed a pneumothorax requiring chest
tube placement, but both of these complications were considered minor
● A small number of patients (5.4%) experienced minor bleeding at the puncture site, but these events were
self-limiting and did not require intervention
The study concluded that ultrasound-guided thoracentesis can be safely performed in patients on NOACs and
clopidogrel, with a low risk of major bleeding or other complications.

8. Safety with NOACS: Mayo Clinic Proceedings
The article aimed to evaluate the safety of ultrasound-guided thoracentesis in patients who were taking novel
oral anticoagulants (NOACs), such as Dabigatran (Pradaxa), Rivaroxaban (Xarelto), Apixaban (Eliquis), Edoxaban
(Savaysa/Lixiana)
The article found that the risk of bleeding complications from thoracentesis in patients on NOACs was low, with
major bleeding events occurring in less than 1% of cases.
No significant difference in the rate of bleeding events between patients taking NOACs or clopidogrel
compared to those not taking these medications.
Individualized management of anticoagulation therapy is necessary to minimize the risk of bleeding
complications

11. Do NOT withhold anticoagulation,
except warfarin

12. General Guidelines for the Periprocedural Management of Thrombotic and
Bleeding Risk in Patients Undergoing Percutaneous Image-Guided Interventions
Society of Interventional Radiology Consensus Guidelines recommends the use of several validated
bleeding risk scores in clinical practice:
HAS-BLED score
CHA2DS2-VASc score
These bleeding risk scores take into account various patient factors, such as age, comorbidities, and
medication use, to estimate the risk of bleeding complications. They can be useful in guiding the
management of anticoagulation and antiplatelet therapy in patients undergoing percutaneous
image-guided interventions.

15. References
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PMC6879671.
Hwang J, Yoon JH, Kim KH, Kim JH, Lee JE, Lim CM, Koh Y, Hong SB. Thoracentesis under clopidogrel is not
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10.1186/s12890-018-0733-2. PMID: 30514244; PMCID: PMC6277162.
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