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

“…In a recent meta-analysis of four studies that were designed specifically to address the role of early TIPS, [3] two studies, both randomised, showed a significant increase in survival, albeit, neither was designed to assess survival as a primary endpoint. [2,4] The other two studies did not find a statistically significant increase in survival, with one including patients with Child-Pugh score to 15 points and thereby, very advanced disease. [5,6] The overall finding of the meta-analysis did suggest that early TIPS increased control of bleeding, decreased rate of re-bleeding and did increase survival.…”

“…[12] A seminal randomised study by Monescillo et al demonstrated that in 116 patients in whom the hepatic venous pressure gradient (HVPG) was performed within 24 hours of an acute variceal bleed, failure to control bleeding and one-year mortality were associated with HVPG >20 mmHg, and that early TIPS reduced treatment failure and mortality. [4] This suggested that haemodynamic factors may define a high-risk group, though clearly HVPG measurement during an index bleed is impractical. It remains to be established whether other surrogates of portal hypertension, such as Fibroscan or real-time shear wave technology, or even platelet count, can be used to predict hepatic dysfunction and optimal candidates for early TIPS.…”

The role of pre-emptive Transjugular Intrahepatic Portosystemic Shunt in acute variceal bleeding: a literature review

“…Deltenre et al 13 conducted the first meta-analysis of its kind and observed reduced rates of mortality and re-bleeding in pre-emptive TIPSS cohorts within 1 year. This well-designed meta-analysis was deliberately stringent on its inclusion and exclusion criteria, limiting the number of included trials to only four papers 8,9,12,14 (see Table 1). Some heterogeneity was observed among the studies; the two earlier RCTs found a significant increase in survival in those who underwent preemptive TIPSS 14 (in contrast to the latter) but did not power the study sufficiently to consider survival as the primary end point.…”

“…It is to be borne in mind that studies looking at the benefit of preemptive TIPSS will inevitably be subject to selection bias, excluding patients who are deemed to be high risk of HE, for example patients with previous episodes of HE. Twelve aforementioned studies have assessed the risk of HE post-TIPSS insertion, with the majority finding that pre-emptive TIPSS within 72 h of admission leads to a significant improvement in relevant clinical outcomes without increasing rates of HE 9,11,13,21 (see Table 1).…”

“…A subsequent study by García-Pagán et al in 2010 8 addressed the drawbacks of the Monescillo et al 9 study by comparing pre-emptive TIPSS with the current standard of care of EBL + NSBB therapy. It offered a simpler, more clinically relevant way of identifying high-risk patients by Child-Pugh score and endoscopic findings (highrisk defined as Child-Pugh C cirrhosis ⩽13 or Child-Pugh B cirrhosis with active bleeding).…”