Through-the-Scope Hemoclips in 2026: What to Deploy Tonight, When to Close a Defect, and When TTS Is Not Enough

Clinical Bottom Line

Clinical question	2026 practical answer
What clip do I pull for a vessel I can face en face?	A reopenable, rotatable TTS clip whose jaw spans the vessel. 11 mm is the workhorse. 16-17 mm for a wider bite. Material (nitinol vs stainless/Elgiloy) is not a hemostasis RCT question.
Active spurting ulcer (FIa/FIb)?	Combination therapy: dilute epinephrine plus TTS clip or contact thermal. ESGE 2026 [3] allows OTS clip monotherapy as an alternative, not a mandate to skip TTS tonight.
Nonbleeding visible vessel (FIIa)?	TTS clip, thermal, or sclerosant, each as monotherapy or plus epinephrine. ACG rates clip RCT evidence weaker than bipolar or heater probe.
When do I clip a polypectomy defect?	Right-colon hot EMR of LNPCPs >=20 mm, when complete closure is feasible. Not for <20 mm. Not routinely for distal large polyps. Details on the clip-closure post.
Large pedunculated polyp?	Ligate the stalk before the snare (clip or endoloop) if head >=20 mm or stalk >=5 mm (USMSTF). Gweon supports pre-resection clipping for heads >=10 mm.
MR after last week's clips?	Almost all current TTS clips are MR Conditional to 1.5 T and 3 T under IFU limits. QuickClip2 is MRI-unsafe. Confirm the exact model. Do not write MRI-safe.
When is TTS the wrong next step?	Fibrotic crater, vessel >2 mm, recurrent bleed after standard therapy, or anatomy that will not take an en-face TTS bite. Escalate to OTSC (OTSC post) or TAE. Do not stack failed TTS clips.

What do I do tonight?

1. If you can face the vessel en face, deploy a reopenable, rotatable TTS clip. 11 mm is the workhorse. 16-17 mm for a wider bite.
2. If this is FIa/FIb ulcer bleeding, combine dilute epinephrine with TTS clip or contact thermal. ESGE 2026 allows OTSC monotherapy as an alternative, not a mandate to skip TTS.
3. If this is FIIa, TTS clip, thermal, or sclerosant can stand as monotherapy.
4. If this is a proximal nonpedunculated EMR defect >=20 mm, close it completely if you can. Partial closure is not prophylaxis.
5. If clips skate off or the defect will not invert, stop stacking TTS clips. That is an OTSC (or surgery) decision. Neighbor: the OTSC article.

What do the societies say?

Do not call these clips MRI-safe. Do not treat CLIP4 (a methylation assay) as a hemostasis RCT. Do not cite the 2023 Annals OTSC trial as Barkun-first; first author is Lau [14].

Which TTS clip should I pull tonight?

Resolution 360 is stainless steel plus cobalt-chromium, not nitinol. QuickClip Pro is Elgiloy. Instinct Plus is the widely used clip that is explicitly nitinol-reinforced. ASGE's 2026 closure-device report lists current jaw widths from about 8 to 22 mm. Pick a reopenable, rotatable clip that can actually span the vessel or defect.

Label clips MR Conditional, not MRI-safe. Resolution contains ferromagnetic material and is MR Conditional at 1.5 T or 3.0 T under IFU limits. QuickClip Pro is MR Conditional to 3 T with tighter SAR/time rules (15 minutes in that IFU). QuickClip2 is MRI-unsafe. Write the brand in the note and send the IFU card with the patient. Gill 2009 is historical bench data. Do not treat "all clips are MRI incompatible" as current labeling.

There is no hemostasis RCT named CLIP4. CLIP4 is a colorectal-cancer methylation assay. Named closure trials are CLIP (Pohl [11]), the Spanish GSEED RCT (Albeniz), Westmead (Gupta), and CLIPPER [12].

Porcine retention data (Shin/Khashab, n=6) showed Instinct and Resolution still attached at 4 weeks and QuickClip2Long gone. That is animal data, not a human day-count guarantee. There is no RCT showing nitinol clips stop more bleeds than stainless or Elgiloy clips.

Do TTS clips beat thermal for ulcer bleeding?

ACG 2021 rec 6: treat active spurting, oozing, and nonbleeding visible vessels. Rec 10: do not use epinephrine as monotherapy. Rec 9 rates clips, APC, or soft monopolar as conditional with low- to very-low-quality evidence, while bipolar, heater probe, and ethanol keep a stronger recommendation. ESGE 2021 treats mechanical therapy as an acceptable second modality for FIa/FIb combination therapy and as monotherapy for FIIa. Say both. Do not launder ACG into "clips are first-line with high-quality evidence."

Sung [7] 2007 (15 RCTs, 1156 patients, older Olympus clips): clips vs injection, definitive hemostasis 86.5% vs 75.4%. Clips vs thermocoagulation, 81.5% vs 81.2%. Failed clip locations: posterior duodenal bulb, posterior gastric body, lesser curve. Laine 2009: clips vs epinephrine, further bleeding RR 0.22, NNT 5. Cipolletta favored clips over heater probe for rebleeding. Lin 2002 went the other way: initial hemostasis 85% clip vs 100% heater probe, and 3/10 vs 9/11 on difficult-to-approach lesions. That split is why "clip first for every ulcer" is wrong. Tangential posterior D1 and high lesser-curve vessels often need a probe, a cap, or OTSC, not a poorly aligned TTS clip.

When should I clip a polypectomy defect?

ESGE 2024 rec 10: prophylactic clip closure after EMR of LNPCPs in the right colon (strong, high-quality). AGA 2024: do not routinely clip sites <20 mm. USMSTF: conditional closure of >=20 mm right-colon defects when feasible, and mechanical ligation of thick pedunculated stalks.

Pohl CLIP: [11] delayed bleeding 3.5% vs 7.1% overall, 3.3% vs 9.6% proximal, no distal benefit. Albeniz: ITT 5% vs 12.1%, but complete closure only 57%, and delayed bleeding 1.5% after complete closure. Gupta: 3.4% vs 10.6%, NNT 14, 75% complete closure at an expert center. CLIPPER (19 Dutch hospitals, pragmatic): 9.0% vs 6.1%, no ITT benefit. Complete-closure delayed bleeding 4.8% vs 19.6% partial vs 33.3% failed. Do not bury CLIPPER. Partial closure is not prophylaxis. The named-trial math lives on the clip-closure post.

Pedunculated polyps are a stalk problem, not a defect problem. Gweon: pre-resection clip vs none for heads >=10 mm, overall postpolypectomy bleeding 4.2% vs 12.6%, mostly immediate. Ji: clip vs endoloop 5.1% vs 5.7%. Both tools are acceptable.

When is TTS not enough?

ESGE 2026 rec 7 puts OTS clips as a monotherapy alternative for FIa/FIb (conditional, very-low-quality evidence). Rec 16 still wants an OTS clip for recurrent peptic ulcer bleeding. TTS-failure cues: fibrotic or excavated base, vessel >2 mm, ulcer >2 cm, posterior D1 or high lesser-curve anatomy, recurrent bleed after a "successful" TTS or thermal session. After two failed TTS or thermal attempts, the next move is a cap-mounted clip or TAE, not clip number 7. Jensen, Lau 2023, STING, and STING-2 are on the OTSC post. Do not copy that trial table here. First author of the 2023 Annals trial is Lau, not Barkun.

Dieulafoy is often an OTSC or combination problem once you have found it. That algorithm is on the Dieulafoy post.

Pitfalls

Pitfall	Better move
Epinephrine monotherapy	Temporary blanching. Recurrence is the rule (ACG rec 10; Sung; Laine).
Stacking TTS clips on a fibrotic ulcer	TTS jaws need pliable mucosa and submucosa. Cap-mounted clip or TAE next.
Tangential posterior D1 or high lesser-curve approach	Classic TTS miss anatomy (Sung; Lin). Reposition, probe, or OTSC.
Routine clipping of <20 mm polypectomy sites	Matsumoto: 1.10% vs 0.87%. Turan IPD: no benefit.
Calling partial EMR closure "clipped"	Albeniz and CLIPPER: the bleed reduction lives in complete closure.
"Nitinol = MRI-safe, steel = MRI-forbidden"	Resolution is steel/cobalt-chrome and MR Conditional. QuickClip Pro is Elgiloy and MR Conditional. QuickClip2 is MRI-unsafe.
Treating CLIPPER as if it erased Pohl and Gupta	CLIPPER is pragmatic daily practice. Expert-center RCTs showed benefit. Complete closure is the likely mediator.

Selected references

1. Laine L, et al. ACG Clinical Guideline: upper GI and ulcer bleeding. Am J Gastroenterol. 2021.
2. Gralnek IM, et al. ESGE Guideline Update: NVUGIH. Endoscopy. 2021.
3. Gralnek IM, et al. ESGE Guideline Update: peptic ulcer bleeding. Endoscopy. 2026.
4. Ferlitsch M, et al. ESGE Guideline Update: colorectal polypectomy and EMR. Endoscopy. 2024.
5. Copland AP, et al. AGA CPU: appropriate and tailored polypectomy. Clin Gastroenterol Hepatol. 2024.
6. ASGE Technology Committee. Endoscopic closure devices. Gastrointest Endosc. 2026.
7. Sung JJY, et al. Endoscopic clipping vs injection and thermocoagulation. Gut. 2007.
8. Laine L, McQuaid KR. Endoscopic therapy for bleeding ulcers. Clin Gastroenterol Hepatol. 2009.
9. Cipolletta L, et al. Endoclips versus heater probe. Gastrointest Endosc. 2001.
10. Lin HJ, et al. Hemoclip versus heater probe for peptic ulcer bleeding. Am J Gastroenterol. 2002.
11. Pohl H, et al. CLIP: clip closure after large colon polyp resection. Gastroenterology. 2019.
12. Kemper G, Turan AS, et al. CLIPPER. Endoscopy. 2025.
13. Gweon TG, et al. Prophylactic clip for large pedunculated polyps. Gastrointest Endosc. 2021.
14. Lau JYW, et al. OTSC vs standard therapy as initial treatment. Ann Intern Med. 2023.
15. Jensen DM, et al. OTSC as initial treatment of severe NVUGIB. Clin Gastroenterol Hepatol. 2021.
16. Matsumoto M, et al. Prophylactic clipping of polyps <20 mm. Dig Endosc. 2016.

Questions doctors ask

Which TTS clip should I pull tonight?

A reopenable, rotatable clip whose jaw spans the vessel. 11 mm is the workhorse. Material (nitinol vs stainless vs Elgiloy) is not a hemostasis RCT question.

Do clips beat thermal for ulcer bleeding?

They match thermal. Both beat injection alone. Combination therapy remains first-line for active spurting.

Are TTS clips MRI-safe?

No. Write MR Conditional. QuickClip2 is MRI-unsafe. Read the IFU for the clip you deployed.

When is TTS not enough?

Large-caliber arteries that clips cannot capture, and defects that will not invert. Change to OTSC rather than stacking failed TTS clips.