Early TIPS with covered stents in high-risk patients with cirrhosis presenting with variceal bleeding: Are we ready to dive into the deep end of the pool?

Abstract

In these patients with cirrhosis who were hospitalized for acute variceal bleeding and at high risk for treatment failure, the early use of TIPS was associated with significant reductions in treatment failure and in mortality.

Consensus conference on TIPS management: Techniques, indications, contraindications

“…Patients with HVPG levels >20 mmHg recorded within 24 h from bleeding [100] or in a Child-Pugh class C (<14 points) or actively bleeding at index endoscopy and in ChildPugh class B [101] have been suggested to have a poor outcome. In such high-risk subjects [101] receiving TIPS within 72 h from bleeding, failure to control bleeding or to prevent rebleeding and mortality were significantly lower (3% vs. 45% and 13% vs. 39% at 1 year, respectively) without an increased risk of HE [102][103][104]. However, in recent surveillance studies, a survival benefit was not observed [102,105], although it approached statistical significance in one [101].…”

Rates of recurrent variceal bleeding are low with modern esophageal banding strategies: a retrospective cohort study

“…The underlying diagnoses of liver disease in our cohort included (patients may be in more than one category): hepatitis C infection 33% (59), alcoholic liver disease 28% (51), hepatitis B infection 12% (21), cryptogenic cirrhosis 12% (21), hepatocellular carcinoma 8% (14), NAFLD 6% (10), portal vein thrombosis 4% (8), primary biliary cirrhosis 4% (8), primary sclerosing cholangitis 3% (6) autoimmune hepatitis 3% (5), Budd-Chiari syndrome 1% (2), one transplant rejection 0.5% (1), other 10% (17/176), unknown 0.5% (1).…”

“…The relatively low incidence of TIPS placement in our cohort may be because many of the patients in this cohort, despite having a history of varices, did not have Child's B or C cirrhosis. The use of TIPS may also be increasing in clinical practice in recent years, as additional studies suggest a benefit in patients with Child's B or C cirrhosis [13,14]. However, many of the patients included in this cohort would have been excluded from TIPS, due to complicated underlying medical conditions.…”

“…Of these, EBL plus pharmacologic b-blockade is the standard of care [8] given its greater efficacy compared to pharmacologic therapy alone [9] and its lower adverse event rate when compared to sclerotherapy [10][11][12]. TIPS is another option that improves outcomes in the setting of an acute variceal bleeding episode, particularly in patients with Child's B and C cirrhosis [13,14].…”

'The TIPSing Point'

“…Treatment with transjugular intrahepatic portosystemic shunt (TIPS) is effective to control bleeding in this population, but has not increased survival rates, likely, as a result of subsequent liver decompensation [3,4]. The strongest evidence in favor of performing TIPS is for secondary prevention of AVB.…”