Early TIPS for portal hypertensive related bleeding: Is resource or education the reason for failure to show clear survival benefit?

Hayes, Peter; Mookerjee, Rajeshwar P.

doi:10.1016/j.jhep.2017.11.001

Cited by 6 publications

(3 citation statements)

References 19 publications

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“…1Although the study was not designed to assess survival and no other comparable randomised control trial has been performed since, international clinical guidelines now suggest placement of an e-PTFE covered TIPSS within 72 hours following acute oesophageal variceal bleeding 2,3. Despite this, physician adherence to these guidelines has been poor, with a lack of technical availability and the ambiguity of current data suggested as possible explanations 6,7. In contrast to previous work, our findings do not support use of early-TIPSS placement for the improvement of survival in cirrhotic patients following oesophageal variceal bleeding.…”

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confidence: 97%

Randomised clinical trial: standard of care versus early‐transjugular intrahepatic porto‐systemic shunt (TIPSS) in patients with cirrhosis and oesophageal variceal bleeding

Dunne

Sinha

Stanley

et al. 2020

Aliment Pharmacol Ther

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Summary Background Early‐transjugular intrahepatic porto‐systemic shunt (TIPSS) has been recommended in international guidelines for high‐risk patients with oesophageal variceal bleeding. Aim To validate the results of a previous randomised control trial which supports use of early‐TIPSS. Methods In a two‐centre open‐label parallel‐group randomised control trial, patients with cirrhosis and acute variceal bleeding were recruited following haemostasis with vaso‐active drugs and endoscopic band ligation. Participants were randomised to standard of care or early‐TIPSS. The primary outcome was 1‐year survival, secondary outcomes included early and late rebleeding, and complications of portal hypertension. Results Fifty‐eight patients (58 ± 11.12 years; 32.7% female) were randomised. After one year, seven patients died in the standard of care group and six in the early‐TIPSS group, a 1‐year survival of 75.9% vs 79.3% respectively (P = 0.79). Variceal rebleeding occurred in eight patients in the standard of care group compared with three patients in the early‐TIPSS group (P = 0.09). Not all participants randomised to early‐TIPSS received the intervention in time. For those receiving TIPSS per‐protocol, variceal rebleeding rates were reduced (0% vs 27.6%, P = 0.04) but this had no effect on survival (76.9% vs 75.9%, P = 0.91). Serious adverse events were similar in both treatment groups, except that rates of hepatic encephalopathy were higher in patients receiving TIPSS (46.1% vs 20.7%, P < 0.05). Conclusions Early‐TIPSS reduced variceal rebleeding, increased encephalopathy but had no effect on survival in high‐risk patients with oesophageal variceal bleeding. Early‐TIPSS may not be feasible in many centres however, larger studies are needed. ClinicalTrials.gov reference: NCT02377141.

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contrasting

confidence: 97%

Randomised clinical trial: standard of care versus early‐transjugular intrahepatic porto‐systemic shunt (TIPSS) in patients with cirrhosis and oesophageal variceal bleeding

Dunne

Sinha

Stanley

et al. 2020

Aliment Pharmacol Ther

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“…Thus, it remains to be established whether other objective surrogates of portal hypertension, such as FibroScan or real-time shear wave technology, can be used to selected optimal candidates for early TIPS. (48) Our study has several limitations. First, these data were a blend of prospectively and retrospectively collected data, and the risk of selection bias is unavoidable.…”

Section: Discussionmentioning

confidence: 91%

“…Thus, it remains to be established whether other objective surrogates of portal hypertension, such as FibroScan or real‐time shear wave technology, can be used to selected optimal candidates for early TIPS. ( 48 )…”

Section: Discussionmentioning

confidence: 99%

Risk Stratification Based on Chronic Liver Failure Consortium Acute Decompensation Score in Patients With Child‐Pugh B Cirrhosis and Acute Variceal Bleeding

Wang

et al. 2021

Hepatology

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Background and Aims Optimal candidates for early transjugular intrahepatic portosystemic shunt (TIPS) in patients with Child‐Pugh B cirrhosis and acute variceal bleeding (AVB) remain unclear. This study aimed to test the hypothesis that risk stratification using the Chronic Liver Failure Consortium Acute Decompensation score (CLIF‐C ADs) may be useful to identify a subgroup at high risk of mortality or further bleeding that may benefit from early TIPS in patients with Child‐Pugh B cirrhosis and AVB. Approach and Results We analyzed the pooled individual data from two previous studies of 608 patients with Child‐Pugh B cirrhosis and AVB who received standard treatment between 2010 and 2017 in China. The concordance index values of CLIF‐C ADs for 6‐week and 1‐year mortality (0.715 and 0.708) were significantly better than those of active bleeding at endoscopy (0.633 [P < 0.001] and 0.556 [P < 0.001]) and other prognostic models. With X‐tile software identifying an optimal cutoff value, patients were categorized as low risk (CLIF‐C ADs <48), intermediate risk (CLIF‐C ADs 48‐56), and high risk (CLIF‐C ADs >56), with a 5.6%, 16.8%, and 25.4% risk of 6‐week death, respectively. Nevertheless, the performance of CLIF‐C ADs for predicting a composite endpoint of 6‐week death or further bleeding was not satisfactory (area under the receiver operating characteristics curve [AUC], 0.588). A nomogram incorporating components of CLIF‐C ADs and albumin, platelet, active bleeding, and ascites significantly improved the prediction accuracy (AUC, 0.725). Conclusions In patients with Child‐Pugh B cirrhosis and AVB, risk stratification using CLIF‐C ADs identifies a subgroup with high risk of death that may derive survival benefit from early TIPS. With improved prediction accuracy for 6‐week death or further bleeding, the data‐driven nomogram may help to stratify patients in randomized trials. Future external validation of these findings in patients with different etiologies is required.

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Early transjugular intrahepatic portosystemic shunt for acute variceal bleeding: a systematic review and meta-analysis

et al. 2021

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Early TIPS for portal hypertensive related bleeding: Is resource or education the reason for failure to show clear survival benefit?

Cited by 6 publications

References 19 publications

Randomised clinical trial: standard of care versus early‐transjugular intrahepatic porto‐systemic shunt (TIPSS) in patients with cirrhosis and oesophageal variceal bleeding

Randomised clinical trial: standard of care versus early‐transjugular intrahepatic porto‐systemic shunt (TIPSS) in patients with cirrhosis and oesophageal variceal bleeding

Risk Stratification Based on Chronic Liver Failure Consortium Acute Decompensation Score in Patients With Child‐Pugh B Cirrhosis and Acute Variceal Bleeding

Early transjugular intrahepatic portosystemic shunt for acute variceal bleeding: a systematic review and meta-analysis

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