Preemptive‐TIPS Improves Outcome in High‐Risk Variceal Bleeding: An Observational Study

Hernández‐Gea, Virginia; Procopeţ, Bogdan; Giráldez, Álvaro; Amitrano, Lucio; Villanueva, Càndid; Thabut, Dominique; Ibáñez‐Samaniego, Luis; Silva‐Junior, Gilberto; Martínez, Javier; Genescà, Joan; Bureau, Christophe; Trebicka, Jonel; Llop, Elba; Laleman, Wim; Palazón, José M.; Castellote, José; Rodrigues, Susana; Gluud, Lise Lotte; Ferreira, Carlos Noronha; Barceló, Rafael Ramís; Cañete, Núria; Rodríguez, Manuel; Ferlitsch, Arnulf; Mundi, José Luis; Grønbæk, Henning; Hernández‐Guerra, Manuel; Sassatelli, Romano; Dell’Era, Alessandra; Senzolo, Marco; Abraldes, Juan G.; Romero–Gómez, Manuel; Zipprich, Alexander; Casas, Meritxell; Masnou, Helena; Primignani, Massimo; Krag, Aleksander; Nevens, Frederik; Calleja, José Luís; Jansen, Christian; Robic, Marie Angèle; Conejo, Irene; Catalina, María‐Vega; Albillos, Agustı́n; Rudler, Marika; Alvarado, Edilmar; Guardascione, Maria Anna; Tanţău, Marcel; Bosch, Jaime; Torres, Ferrán; García‐Pagán, Juan Carlos

doi:10.1002/hep.30182

Cited by 143 publications

(186 citation statements)

References 23 publications

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“…Furthermore, our data demonstrated that early TIPS improved survival among Child-Pugh B patients with active bleeding. This finding is at odds with a recent large observational study by Hernández-Gea et al 28 that failed to show a survival benefit in this subgroup of patients. However, with only 19 patients with Child-Pugh class B and active bleeding in their study, the sample may not have been large enough with sufficient statistical power to detect a difference.…”

Section: Discussionmentioning

confidence: 58%

Identifying optimal candidates for early TIPS among patients with cirrhosis and acute variceal bleeding: a multicentre observational study

Zuo

Zhu

et al. 2018

Gut

104

141

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ObjectivesEarly placement of transjugular intrahepatic portosystemic shunt (TIPS) has been shown to improve survival in high-risk patients (Child-Pugh B plus active bleeding at endoscopy or Child-Pugh C 10–13) with cirrhosis and acute variceal bleeding (AVB). However, early TIPS criteria may overestimate the mortality risk in a significant proportion of patients, and the survival benefit conferred by early TIPS in such patients has been questioned. Alternative criteria have been proposed to refine the criteria used to identify candidates for early TIPS. Nevertheless, the true survival benefit provided (or not) by early TIPS compared with standard treatment in the different risk categories has not been investigated in specifically designed comparative studies.DesignWe collected data on 1425 consecutive patients with cirrhosis and AVB who were admitted to 12 university hospitals in China between December 2010 and June 2016. Of these, 206 patients received early TIPS, and 1219 patients received standard treatment. The Fine and Gray competing risk regression model was used to compare the outcomes between the two groups that were stratified based on the currently available risk stratification systems after adjusting for liver disease severity and other potential confounders.ResultsOverall, early TIPS was associated with an 80% relative risk reduction (RRR) in mortality at 6 weeks (adjusted HR=0.20; 95% CI: 0.10 to 044; p<0.001) and 51% RRR at 1 year (adjusted HR=0.49, 95% CI: 0.32 to 0.73; p<0.001) compared with standard treatment. In stratification analyses, the RRRs in mortality did not significantly differ among the risk categories. However, the absolute risk reductions (ARRs) of mortality were more pronounced in high-risk patients. The ARRs at 6 weeks were −2.1%, −10.2% and −32.4% in Model for End-stage Liver Disease (MELD) ≤11, 12–18 and ≥19 patients and were −1.5%, −9.1% and −23.2% in Child-Pugh A, B and C patients, respectively (interaction tests, p<0.001 for both criteria). The ARRs for mortality at 1 year were −1.7%, −5.4% and −32.7% in MELD ≤11, 12–18 and ≥19 patients, respectively, and −3.6%, −5.2% and −20.3% in Child-Pugh A, B and C patients, respectively (interaction tests, p<0.001 for both criteria). After adjusting for liver disease severity and other potential confounders, a survival benefit was observed in MELD ≥19 or Child-Pugh C patients but not in MELD ≤11 or Child-Pugh A patients. In MELD 12–18 patients, a survival benefit was observed within 6 weeks but not at 1 year. In Child-Pugh B patients, a survival benefit was observed in those with active bleeding but not those without active bleeding. However, the evaluation of active bleeding was associated with a high interobserver variability. Furthermore, early TIPS was associated with a significantly reduced incidence of failure to control bleeding or rebleeding and new or worsening ascites, without increasing the risk of overt hepatic encephalopathy.ConclusionsEarly TIPS was associated with improved survival in patients with MELD ≥19 or Child-Pugh C ...

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Section: Discussionmentioning

confidence: 58%

Identifying optimal candidates for early TIPS among patients with cirrhosis and acute variceal bleeding: a multicentre observational study

Zuo

Zhu

et al. 2018

Gut

104

141

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“…Results from a prospective study of early TIPS in a large cohort of high‐risk patients were recently reported by Hernandez‐Gea et al Early TIPS reduced the 1‐year probability of treatment failure and rebleeding compared to drug and endoscopic therapy (92% vs 74%; P < .01) with no increase in hepatic encephalopathy.…”

Section: Introductionmentioning

confidence: 72%

“…Volume restitution should be initiated to restore haemodynamic stability. Packed red blood cell transfusion should be performed with a target haemoglobin level of be- Results from a prospective study of early TIPS in a large cohort of high-risk patients were recently reported by Hernandez-Gea et al 28 Early TIPS reduced the 1-year probability of treatment failure and rebleeding compared to drug and endoscopic therapy (92% vs 74%; P < .01) with no increase in hepatic encephalopathy.…”

Section: What's New In the Treatment Of Portal Hypertension?mentioning

confidence: 84%

What's new in portal hypertension?

Mauro

Gadano

2020

Liver International

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Portal hypertension is defined as increased pressure in the portal venous system. The most common cause of portal hypertension is cirrhosis. In this setting, there is an increase in intrahepatic resistance leading to an increase in portal pressure. By increasing portal blood flow, splanchnic vasodilation further aggravates portal hypertension. New pathogenic pathways are being established which might result in new therapeutic strategies. The presence of varices at endoscopy and/or other abdominal portosystemic collaterals confirms the diagnosis of portal hypertension. The role of non‐invasive and imaging tests in the diagnosis and prognosis of portal hypertension has been clarified. Non‐selective beta‐blockers decrease both the risk of variceal haemorrhage and hepatic decompensation. Terlipressin, somatostatin or octreotide, in combination with early endoscopic therapy, are recommended for the treatment of acute variceal haemorrhage. Early Transjugular intrahepatic portosystemic shunt (TIPS) is effective as salvage therapy in acute variceal bleeding in selected patients and prevents rebleeding more effectively than endoscopic and medical therapy resulting in an increased survival.

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“…We appreciate Jian He and Leng Ai-Min for their interest in our study published in Hepatology. (1) First, they bring up the possibility that patients included in our report may have consumed certain over-the-counter hepatoprotective agents (e.g., glutathione, diammonium glycyrrhizinate, or polyene phosphatidyl choline) as antioxidants to improve their liver health and that such use may have confounded our study results. We agree that it is a possibility, but at our center, which is located in the midwestern United States, awareness among our patients that oxidative stress may have an important role in the pathogenesis of nonalcoholic steatohepatitis and its progression is not high.…”

Section: Replymentioning

confidence: 99%

“…I read with interest the use of preemptive TIPS (transjugular intrahepatic porto-systemic stent shunt) in patients with high-risk variceal bleeding. (1) Because the mortality of Child-Pugh class C patients was significantly reduced in patients receiving preemptive TIPS, the authors concluded that preemptive TIPS must be the treatment of choice in Child-Pugh class C patients with acute variceal bleeding. (1) However, this conclusion warrants further clarification.…”

Section: Letter To the Editor: Preemptive Tips Must Be The Treatment mentioning

confidence: 99%

Letter to the Editor: Preemptive TIPS Must Be the Treatment of Choice for Child‐Pugh Class C Patients With Variceal Bleeding?

2019

Hepatology

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Preemptive‐TIPS Improves Outcome in High‐Risk Variceal Bleeding: An Observational Study

Abstract: p-TIPS must be the treatment of choice in CP-C patients with AVB. Due to the strong benefit in preventing further bleeding and ascites, p-TIPS could be a good treatment strategy for CP-B+AB patients. This article is protected by copyright. All rights reserved.

Cited by 143 publications

References 23 publications

Identifying optimal candidates for early TIPS among patients with cirrhosis and acute variceal bleeding: a multicentre observational study

Identifying optimal candidates for early TIPS among patients with cirrhosis and acute variceal bleeding: a multicentre observational study

What's new in portal hypertension?

Letter to the Editor: Preemptive TIPS Must Be the Treatment of Choice for Child‐Pugh Class C Patients With Variceal Bleeding?

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