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Preemptive-TIPS Improves Outcome in High-Risk Variceal Bleeding: An Observational Study

Virginia Hernández-Gea1,2, Bogdan Procopet3, Álvaro Giráldez4

  • 1Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic-Institut d'Investigacions Biomèdiques August Pi I i Sunyer, IMDIM, University of Barcelona, Barcelona, Spain.

Hepatology (Baltimore, Md.)
|July 18, 2018
PubMed

Insights

Preemptive transjugular intrahepatic portosystemic shunt (p-TIPS) significantly lowers mortality in Child-Pugh C patients with acute variceal bleeding. It also reduces treatment failure and rebleeding in high-risk patients.

Area of Science:

  • Hepatology
  • Interventional Radiology
  • Gastroenterology

Background:

  • Patients with acute variceal bleeding (AVB) and advanced liver disease (Child-Pugh C or B with active bleeding) face high risks of treatment failure, rebleeding, and death.
  • Preemptive transjugular intrahepatic portosystemic shunt (p-TIPS) shows potential to improve outcomes but is not widely adopted in clinical practice.
  • This study aimed to validate the efficacy of p-TIPS in a large cohort of high-risk AVB patients.

Purpose of the Study:

  • To evaluate the effectiveness of preemptive transjugular intrahepatic portosystemic shunt (p-TIPS) versus standard drug and endoscopic therapy (D+E) in high-risk patients with acute variceal bleeding (AVB).
  • To assess the impact of p-TIPS on mortality, treatment failure, rebleeding, ascites, and hepatic encephalopathy in Child-Pugh C (CP-C) and Child-Pugh B with active bleeding (CP-B+AB) patients.

Main Methods:

  • A multicenter, international, observational study involving 671 patients admitted with AVB and high risk for treatment failure.
  • Patients were treated with either standard drug and endoscopic therapy (D+E) or preemptive transjugular intrahepatic portosystemic shunt (p-TIPS), based on center policy.
  • Outcomes including mortality, treatment failure, rebleeding, ascites, and hepatic encephalopathy were compared between treatment groups.

Main Results:

  • In Child-Pugh C patients, p-TIPS was associated with significantly lower 1-year mortality compared to D+E (22% vs. 47%, P=0.002).
  • For Child-Pugh B with active bleeding patients, p-TIPS did not significantly improve the low mortality rate but reduced treatment failure and rebleeding.
  • Across both high-risk groups, p-TIPS significantly decreased the incidence of treatment failure and rebleeding (1-year CIF 92% vs. 74% for D+E, P=0.017) and ascites development, without increasing hepatic encephalopathy.

Conclusions:

  • Preemptive transjugular intrahepatic portosystemic shunt (p-TIPS) should be considered the primary treatment for Child-Pugh C patients experiencing acute variceal bleeding.
  • Given its efficacy in preventing further bleeding and ascites, p-TIPS presents a valuable treatment strategy for Child-Pugh B patients with active bleeding.

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