Early Use of TIPS in Patients with Cirrhosis and Variceal Bleeding

García‐Pagán, Juan Carlos; Caca, Karel; Bureau, Christophe; Laleman, Wim; Appenrodt, Beate; Luca, Angelo; Abraldes, Juan G.; Nevens, Frederik; Vinel, Jean Pierre; Mössner, Joachim; Bosch, Jaime

doi:10.1056/nejmoa0910102

Cited by 1,075 publications

(873 citation statements)

References 23 publications

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“…According to the results reported by Maiwall et al, 89% of patients receiving SEMS had achieved hemostasis at 5 days and also had a significantly higher actuarial probability of 6-week survival than patients in the propensity score-matched cohort even though the 6-week mortality in SEMS-treated patients was very high at 81%. The results of this study also confirm the observation by García-Pagán et al on the lack of survival benefit of rescue TIPS, as compared with its preemptive use [9].…”

supporting

confidence: 91%

“…This is the rationale for preemptive or early TIPS [8]. Indeed, two RCT [9,10] and two observational studies confirm the efficacy of early TIPS (within the first 72 h after admission) in such high-risk patients. Indeed, experts attending the Baveno VI consensus conference recommended the use of early TIPS in patients with Child-Pugh B cirrhosis and active bleeding despite vasoactive drug therapy and in all patients with Child-Pugh C cirrhosis (< 14 points) [3].…”

mentioning

confidence: 97%

“…A second approach is to identify those patients at high risk of treatment failure and manage them more aggressively in order to prevent further deterioration and death despite final control of bleeding [9]. This is the rationale for preemptive or early TIPS [8].…”

mentioning

confidence: 99%

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Esophageal Stents for Acute Variceal Bleeding: Expanding the Possibilities

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confidence: 97%

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Esophageal Stents for Acute Variceal Bleeding: Expanding the Possibilities

2017

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“…In selected patients, TIPS decompresses the portal venous system, successfully treats ascites and variceal bleeding, and improves survival 14, 15, 16, 17. However, AD of liver cirrhosis can progress and develop into acute‐on‐chronic liver failure (ACLF) with poor survival 18.…”

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confidence: 99%

Acute decompensation boosts hepatic collagen type III deposition and deteriorates experimental and human cirrhosis

Praktiknjo

Lehmann

Nielsen

et al. 2018

Hepatology Communications

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Patients with end‐stage liver disease develop acute decompensation (AD) episodes, which become more frequent and might develop into acute‐on‐chronic liver failure (ACLF). However, it remains unknown how AD induces acceleration of liver disease. We hypothesized that remodeling of collagen type III plays a role in the acceleration of liver cirrhosis after AD and analyzed its formation (Pro‐C3) and degradation (matrix metalloproteinase‐degraded type III collagen [C3M]) markers in animal models and human disease. Bile duct ligation induced different stages of liver fibrosis in rats. Fibrosis development (hydroxyprolin content, sirius red staining, α‐smooth muscle actin immunohistochemistry, messenger RNA of profibrotic cytokines), necroinflammation (aminotransferases levels), fibrolysis (matrix metalloproteinase 2 expression and activity, C1M, C4M), and Pro‐C3 and C3M were analyzed 2, 3, 4, 5, and 6 weeks after bile duct ligation (n = 5 each group). In 110 patients with decompensated liver cirrhosis who underwent a transjugular intrahepatic portosystemic shunt procedure for AD, clinical and laboratory parameters as well as Pro‐C3 and C3M were measured in blood samples from portal and hepatic veins and were collected just before the transjugular intrahepatic portosystemic shunt placement and 1‐3 weeks later. Animal studies showed increased markers of collagen type III deposition with fibrosis, necroinflammation, and decompensation of liver cirrhosis, defined as ascites development. Higher Pro‐C3 levels were associated with injury, disease severity scores (Model for End‐Stage Liver Disease, Child‐Pugh, chronic liver failure‐C AD), ACLF development, and mortality. C3M decreased with AD and the chronic liver failure‐C AD score. Collagen type III deposition ratio increased with the risk of ACLF development and mortality. Conclusion: We show for the first time that AD boosts collagen type III deposition in experimental and human cirrhosis, possibly contributing to the worsened outcome in patients with decompensated cirrhosis. (Hepatology Communications 2018;2:211–222)

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Survival in Cirrhotic Patients with High MELD Scores: The TIPping Point

Hwang

Sze

2016

Dig Dis Sci

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Although a survival benefit following transjugular intrahepatic portosystemic shunt (TIPS) creation for variceal bleeding [1] and ascites [2,3] has been reported in randomized controlled trials (RCTs) in cirrhotic patients, clinical outcomes after TIPS placement in patients with late-stage liver disease and high Model for End-Stage Liver Disease (MELD) scores remain controversial. The MELD score was originally created to predict the survival after TIPS placement in patients with cirrhosis; by intention, a high MELD score predicts poor survival after TIPS [4]. While the RCTs supported early TIPS placement for variceal bleeding and favored TIPS over repeated large-volume paracentesis in patients with Child-Pugh scores up to 11 or 13, the investigators intentionally excluded patients with severely compromised liver function and higher scores. The RCTs also did not report on outcomes relative to the MELD scores.Consequently, data regarding TIPS outcomes in patients with high MELD scores have historically been derived from non-randomized studies. Angermayr et al. [5] reported a 60% 1-year mortality rate in patients with MELD [ 18. Ferral et al. [6] reported a 90-day mortality rate of 34.8% in patients after elective TIPS with MELD scores of 18-24 and 65.5% in patients with MELD C 18, yielding a 90-day mortality of 44% for all patients with MELD C 18. Casadaban et al. [7] stated that survival rates after emergent TIPS placement for acute variceal bleeding were predicted by MELD scores and were inferior to survival rates reported in the elective TIPS placement population, with a 90-day mortality rate of 36% for MELD 19-25 and 83% for MELD C 26.The high post-TIPS mortality rates reported in patients with high MELD scores have led some to conclude that TIPS procedures should not be performed in those patients, particularly if the MELD is [25 [6]. Although such a conclusion implies that TIPS placement is harmful, or at least, not beneficial to that subset of patients, this assumption remains conjectural. The prognosis of patients with high MELD scores is generally poor, with reported 1-year mortality of approximately 30% for MELD scores between 20 and 29 and approximately 60% for MELD scores C30 [8]. Given the variability among patient cohorts in how MELD scores are stratified, and in how survival outcomes are reported, and given the similarities in the reported survival statistics for high-MELD patients with and without TIPS, it is difficult to isolate the effect of TIPS placement from the overall dismal survival typical of high-MELD patients.In this issue of Digestive Diseases and Sciences, Ascha et al. [9] have taken a step toward answering the question of whether TIPS placement increases or decreases survival in patients with high MELD scores. They retrospectively analyzed a cohort of 144 patients with MELD score C15 who underwent TIPS procedures, matched them by MELD score and age to 144 patients who had not undergone TIPS procedures, excluding patients with hepatocellular carcinoma or those who died within 48 h of ...

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Early Use of TIPS in Patients with Cirrhosis and Variceal Bleeding

Cited by 1,075 publications

References 23 publications

Esophageal Stents for Acute Variceal Bleeding: Expanding the Possibilities

Esophageal Stents for Acute Variceal Bleeding: Expanding the Possibilities

Acute decompensation boosts hepatic collagen type III deposition and deteriorates experimental and human cirrhosis

Survival in Cirrhotic Patients with High MELD Scores: The TIPping Point

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