p-TIPS improves outcomes for high-risk variceal bleeding
Background: Acute variceal bleeding remains the most severe and life-threatening complication of portal hypertension in cirrhotic patients. Several small studies have shown improved outcomes with p-TIPS without worsening of hepatic encephalopathy or other adverse events.
Study design: Multicenter, international, observational study.
Setting: One Canadian and 33 European referral centers.
Synopsis: 2,138 patients were registered for analysis, of which 671 were identified as high risk based on Child-Pugh score (either Child class C of less than 14 or Child class B with active bleeding seen on endoscopy). Multiple exclusion criteria were used including Child-Pugh score of 14 or more, renal failure, occlusive portal vein thrombosis, sepsis, heart failure, or hepatocellular carcinoma outside Milan criteria. Each patient underwent initial management with vasoactive medications, antibiotics, and endoscopy with subsequent intervention (p-TIPS vs. standard care) based on provider decision. p-TIPS was defined as TIPS within 72 hours of initial bleed. 31.4% of the cohort was lost to follow-up at 1 year. p-TIPS improved 1-year mortality significantly (78% vs. 62%; P = .014) and did not confer an increased risk of hepatic encephalopathy or other complication. Additionally, the authors found that the effect was significantly greater in the Child-Pugh Class C group (1-year mortality rate of 78% vs. 53%; P = .002). The authors then compared observed mortality with MELD-predicted mortality and found that with standard care, MELD scores matched with predicted mortality, but with p-TIPS, MELD scores predicted a greater mortality than the observed mortality. The authors calculated that the number needed to treat to save one life for 1 year with p-TIPS is 4.2. The major limitation of this study is the observational design and the inherent risk of selection bias. Additionally, almost one-third of patients were lost to follow-up.
Bottom line: Significant improvements in mortality are observed when high-risk patients undergo p-TIPS procedures as opposed to usual care with medications and endoscopy.
Citation: Hernández Gea V et al. Preemptive TIPS improves outcome in high risk variceal bleeding: An observational study. Hepatology. 2018 Jul 16. doi: 10.1002/hep.30182.
Dr. Imber is an assistant professor in the division of hospital medicine, University of New Mexico.
