The two-layered cross technique for post-over-the-scope clip bleeding

Fig. 1 Schematic of initial over-the-scope (OTS) clip placement.a When the direction of occlusion of the OTS clip claw aligns with the direction of the vessel, the vessel is occluded by the claw, and hemostasis is achieved.b If the direction of occlusion of the OTS clip claw does not align with the vessel's direction, the blood vessel may pass between the clip's nail and hinge, resulting in failed hemostasis, even if the clip appears to be properly placed. Fig. 2 Schematic of a second OTS clip placed in the standard orientation for post-OTS-clip bleeding.a Before OTS clip release.b After OTS clip release.Since the orientation of the claws on both the first and second OTS clip is identical, the second clip may fail to stop the bleeding because the vessel may again pass between the nail and hinge.