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

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.