Transjugular intrahepatic portosystemic shunt versus endoscopic sclerotherapy for the prevention of variceal rebleeding after recent variceal hemorrhage

Abstract

Variceal hemorrhage continues to be a major cause of morbidity and mortality in cirrhotic patients. Transjugular intrahepatic portosystemic shunt (TIPS) is gaining wide acceptance as a treatment for several complications of portal hypertension. The aim of the current randomized study was to compare the transjugular shunt and endoscopic sclerotherapy (ES) for the prevention of variceal rebleeding (VB) in cirrhotic patients. Forty-six consecutive cirrhotic patients with variceal bleeding were randomly allocated to receive either transjugular shunt (22 patients) or ES (24 patients) 24 hours after control of bleeding. VB (50% vs. 9%) and early (first 6 weeks) VB (33% vs. 5%) were significantly more frequent in sclerotherapy patients; the actuarial probability of being free of VB was higher in the shunt group (P F .002). Eight patients (33%) of the sclerotherapy group and 3 patients (15%) of the shunt group died; the actuarial probability of survival was higher for the shunted patients (P F .05); 6 patients in the sclerotherapy group and none in the shunt group died from VB (P F .05). No difference was found in the proportion of patients with clinically evident hepatic encephalopathy (HE). These results show that the transjugular shunt is more effective than sclerotherapy in the prevention of both early and long-term VB. Moreover, a significant improvement in survival was found in the shunt group. (HEPATOLOGY 1999;29:27-32.)Variceal bleeding in cirrhotic patients is the most important complication of portal hypertension for two main reasons: the high mortality of each episode of bleeding and the high proportion of patients that rebleed with the associated additional risk of death. 1,2 This second fact makes mandatory the application of therapeutic strategies to prevent recurrent hemorrhage. 3 The best results in terms of rebleeding prevention are obtained by surgical portal systemic shunts but are associated with high procedural mortality and high incidence of encephalopathy; this has limited its wide application and has encouraged investigations on other therapeutic options like endoscopic sclerotherapy (ES) and band ligation and drugs. 4 More recently, transjugular intrahepatic portosystemic shunt (TIPS) has been introduced in clinical use for several complications of portal hypertension 5 ; it enables the decompression of the portal venous system by means of a communication between the hepatic and the portal veins through the liver parenchyma with a percutaneous approach avoiding the risks and limitations of surgery. Several initial series have suggested that it could be of great value for variceal bleeding, 6,7 but data from comparative studies with accepted therapies are scarce. [8][9][10][11][12][13][14][15] Our aim was to compare TIPS with a widely accepted therapy with low procedural mortality and morbidity and low inclusion limitations, like ES, for the prevention of variceal rebleeding (VB) in cirrhotic patients. PATIENTS AND METHODSStudy Design. All patients presenting with a variceal hemorrhage were resusc...

The role of transjugular intrahepatic portosystemic shunt in the management of portal hypertension

“…36,37,39 -41 The incidence of stenosis varies from 18% to 78% depending upon the surveillance techniques used, frequency of assessment, and definitions of failure, (e.g., elevated portasystemic gradient, ultrasound velocity criteria, or percent diameter stenosis). 9,11,12,[42][43][44][45][46] Most physicians rely on Doppler ultrasound to identify TIPS stenosis. Unfortunately, the earlier studies claiming greater than 90% accuracy for sonographic prediction of shunt dysfunction have failed to stand under the light of larger prospective or retrospective studies.…”

Comparison of MELD, Child-Pugh, and Emory model for the prediction of survival in patients undergoing transjugular intrahepatic portosystemic shunting

“…Accordingly, in our present study areas under the ROC curves for the prediction of survival were calculated for each scoring model at different times (3,12, and 36 months after TIPS placement). For this analysis, to avoid a selection bias due to early mortality, we included only the patients who had died during the respective follow-up, who had been treated with TIPS at 3, 12, or 36 months before the end of observation.…”

“…The transjugular intrahepatic portosystemic stent shunt (TIPS) is an effective treatment of major complications of portal hypertension, namely variceal hemorrhage (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12) and refractory ascites (13,14). However, although the rate of recurrent variceal bleeding can successfully be reduced by TIPS insertion, the majority of controlled trials (3)(4)(5)(6)(7)(8)(9)(10) and the meta-analyses (15,16) failed to demonstrate a survival benefit when compared with alternative treatments.…”

Transjugular intrahepatic portosystemic shunt compared with endoscopic treatment for prevention of variceal rebleeding: A meta-analysis

“…Thus, several randomized controlled studies were conducted to evaluate objectively the efficacy of TIPS in this setting. TIPS has been compared with sclerotherapy (with or without the addition of propanolol) and with ligation and has been found to be superior for prevention of rebleeding in most, but not all, 13 studies and equal 14,15 or inferior 13 or superior 16 in terms of survival. To critically appraise and bring together the current evidence on TIPS for prevention of rebleeding, we performed a meta-analysis of the results of randomized trials comparing TIPS with ET.…”