Effect of time to pre‐emptive transjugular intrahepatic portosystemic shunt on patient outcome, a UK multicentre cohort study

Abstract

Summary Background Pre‐emptive transjugular intrahepatic portosystemic shunt (pTIPSS) should be considered within 72 hours following acute oesophageal variceal bleeding. However, recent studies highlight the difficulty in providing pTIPSS within this narrow timeframe. Delaying pTIPSS beyond 72 hours has not been studied. Aim To determine if the time taken to perform pTIPSS alters patient outcome. Method Patients referred to 4 UK tertiary centres for pTIPSS between 01 January 2010 and 31 December 2018 were included. Time from endoscopy to pTIPSS was recorded and pre‐defined clinically relevant outcomes were observed relative to two groups: early pTIPSS (<72 h) and late pTIPSS (72 h–28 days). The primary outcome was transplant‐free survival at 1‐year. Follow‐up was until 31 December 2020. Results A total of 83 patients received early pTIPSS and 88 received late pTIPSS. Baseline characteristics were similar with no requirement for propensity score‐matched analysis. There was no difference between early and late pTIPSS groups for patient outcomes; 1‐year transplant‐free survival rate (69.9% vs 71.6%, p = 0.73, HR 0.91, 95% CI 0.52–1.58), long‐term survival (p = 0.52, HR 1.132, 95% CI 0.77–1.65), variceal rebleeding (4.82% vs 11.36%, p = 0.09, HR 0.411, 95% CI 0.14–1.17), hepatic encephalopathy (43.93% vs 34.61%, p = 0.26) and new or worsening ascites (16.6% vs 13.46%, p = 0.79). Death due to liver failure was significantly more prevalent in those undergoing early pTIPSS compared to late pTIPSS (44% vs 16%, p = 0.046, HR 2.79, 95%CI 1.02–8.32). Conclusion Placement of pTIPSS within 72 hours offered similar short‐ and long‐term survival benefits compared to pTIPSS placed between 72 hours and 28 days. Early pTIPSS may be associated with an increased risk of liver failure‐related mortality. Further large, randomised studies are required to evaluate these findings.

Pre-emptive TIPS in high-risk acute variceal bleeding. An updated and revised individual patient data meta-analysis

“…This suggests that delaying interventions will likely result in selecting patients with better spontaneous survival, which can lead to survival bias in clinical trials. Recent studies have suggested that delaying p-TIPS placement until 28 days after admission may result in even greater survival benefits than placing p-TIPS within 72 hours of admission 28 . However, our results show that any intervention applied to patients who have already survived will be associated with better survival.…”

“…Recent studies have suggested that delaying p-TIPS placement until 28 days after admission may result in even greater survival benefits than placing p-TIPS within 72 hours of admission. [28] However, our results show that any intervention applied to patients who have already survived will be associated with better survival. For example, a patient who was initially classified as Child C at admission would have much better survival if the decision for a p-TIPS is delayed for 3 weeks.…”

The time window for pre-emptive transjugular intrahepatic portosystemic shunt could be extended to 5 days

“…Thus, as mentioned in the Baveno VII consensus, it is necessary to assess whether pTIPS performed outside the 72-h window is still effective and safe [ 5 ]. Dunne P et al compared the clinical outcomes of early pTIPS (<72 h) and late pTIPS (72h-28 days) and similar short- and long-term survival benefits between the two groups were found [ 27 ]. The same results were observed in our study, but unlike the study conducted by Dunne P et al, we defined the time window for late pTIPS as 72 h-5d because the time frame for AVB is 5 d as defined by the Baveno consensus [ 10 ].…”

Transjugular intrahepatic portosystemic shunt for pyrrolidine alkaloids-induced hepatic sinusoidal obstruction syndrome: a retrospective cohort study

“…With regard to liver and kidney function, this study indicated that the serum TB and DB levels of patients at 1 day – 1 month after TIPS were higher than those preoperatively, which may be associated with the transient injury of liver function brought about by TIPS surgery. TIPS allowed portal vein blood to enter the systemic circulation directly without passing through the liver parenchyma, thus aggravating hypoxia and ischemia in liver cells [26,27]. Subsequently, serum TB and DB decreased gradually and liver function improved, though bilirubin levels did not return to normal ranges 3 months after operation.…”