Intervenciones endovasculares reducen la resangrado en pacientes con várices gástricas: un metaanálisis de datos de...

There is no consensus on the optimal modality of secondary prophylaxis for gastric variceal (GV) bleeding in patients with cirrhosis.

Observational studies and randomized controlled trials (RCTs) comparing endovascular interventions-balloon occluded retrograde transvenous obliteration [BRTO] and transjugular intrahepatic portosystemic shunt [TIPS] with endoscopic cyanoacrylate injection (ECI) were considered for the aggregate data meta-analysis (ADMA). Individual patient data was collected from RCTs to perform an individual patient data meta-analysis (IPDMA) in a propensity score matched cohort. Primary outcome was comparison of the rates of all-cause rebleeding between ECI, BRTO and TIPS. Secondary outcomes included overall survival, ascites and hepatic encephalopathy (HE).

Fifteen studies (11 observational and 4 RCTs) comprising 1240 patients (ECI: 377, BRTO: 575, TIPS: 288) were included in the ADMA. In the IPDMA, both BRTO (sHR: 0.15; 95% CI: 0.05-0.43; p=0.004) and TIPS (sHR: 0.49; 95% CI: 0.27-0.89; p=0.019) significantly reduced all-cause rebleeding compared to ECI, without survival benefit. BRTO was associated with higher risk of new-onset or worsening of pre-existing ascites (sHR: 3.54; 95% CI: 1.31-9.55, p=0.013); TIPS increased risk of HE (sHR: 8.84; 95% CI: 2.0-39.11, p=0.004) compared to ECI. Benefit in rebleeding reduction was most pronounced among patients with Child-Pugh Class-B cirrhosis. The analysis revealed limited long-term outcome data, inconsistencies in reported trial outcomes and significant heterogeneity in results, particularly regarding TIPS.

Endovascular interventions (BRTO and TIPS) are superior to ECI for reducing all-cause rebleeding in patients with cirrhosis and GV hemorrhage. Larger studies with standardized end-points and long-term outcomes are needed to clarify survival benefit and optimize treatment selection.