Safety of Ultrasound-guided Small-Bore Chest Tube Insertion in Patients on Clopidogrel

Background: The safety of small-bore chest tubes insertion with ultrasound (US) guidance has been well demonstrated in patients not receiving antiplatelet therapy. Given the current widespread use of these agents, pulmonologists frequently encounter patients on this therapy and requiring drainage of the pleural space. The use of these agents clearly increases the risk of bleeding, but it is not always possible to stop this therapy before the procedure, especially in patients requiring urgent drainage and those with coronary stents. The purpose of this study is to report our experience on the safety of US-guided small-bore chest tube placement in patients receiving clopidogrel. Methods: This was a retrospective review of the charts of adult patients who underwent small-bore chest tube insertion by the pulmonary service while on clopidogrel. Data collected included patient's and effusion characteristics, indication for clopidogrel and for the procedure, and any significant bleeding complication defined as hemothorax, chest wall hematoma, a reduction in hemoglobin of > 2 g/dL, or any bleeding requiring blood transfusion, surgery, or chest tube insertion. US of the chest was performed before insertion but did not include Doppler study of intercostal arteries. Lateral insertion at or anterior to the posterior axillary line was the preferred choice when possible. Results: Forty-three procedures were performed in 30 patients. Seventy percent were male with a mean age of 71 years. The indications for clopidogrel were coronary stents (50%), acute coronary syndrome (27%), prevention of graft occlusion after coronary artery bypass graft (CABG) (13%), femoral stent or endarterectomy (7%), and carotid endarterectomy (3%). The etiology of the effusions was post-CABG (43%), heart failure (17%), end-stage renal disease (13%), pneumothorax (10%), and others (17%). The procedures were therapeutic in 41 cases and diagnostic in 2. The indications for the procedure were respiratory distress (65%), respiratory failure (23%), and pneumothorax (7%). Fifteen procedures (35%) were performed in 10 patients in the ICU and 6 of them were mechanically ventilated. Nine patients were obese based on body mass index. Neither significant bleeding nor other minor complications were seen. Conclusions: The insertion of small-bore chest tube in patients receiving clopidogrel can be safe if performed by experienced operators and by using US guidance along with lateral insertion site, which has the lowest risk of lacerating the intercostal arteries.