Effects of Early Placement of Transjugular Portosystemic Shunts in Patients With High-Risk Acute Variceal Bleeding: a Meta-analysis of Individual Patient Data

International Variceal Bleeding Study and Baveno Cooperation Study groups Preemptive TIPS Individual Data Metanalysis, Oana Nicoară-Farcău, Guohong Han, Marika Rudler, Debora Angrisani, Alberto Monescillo, Ferran Torres, Georgina Casanovas, Jaime Bosch, Yong Lv, Dominique Thabut, Daiming Fan, Virginia Hernández-Gea, Juan Carlos García-Pagán, Christophe Bureau, Juan G. Abraldes, Frederik Nevens, Karel Caca, Wim Laleman, Beate AppenrodtAngelo Luca, Jean Pierre Vinel, Joachim Mössner, Marco Di Pascoli, Alexander Zipprich, Tilman Sauerbruch, Francisco Martinez-Lagares, Luis Ruiz-del-Arbol, Angel Sierra, Clemencia Guevara, Elena Jimenez, Jose Miguel Marrero, Enrique Buceta, Juan Sanchez, Ana Castellot, Monica Penate, Ana Cruz, Elena Pena, Bogdan Procopeț, Álvaro Giráldez, Lucio Amitrano, Candid Villanueva, Luis Ibañez-Samaniego, Gilberto Silva-Junior, Javier Martinez, Joan Genescà, Jonel Trebicka, Elba Llop, Romano Sassatelli, Massimo Primignani, Vincenzo La Mura

Research output: Contribution to journalArticlepeer-review

Abstract

Background & Aims: Compared with drugs plus endoscopy, placement of transjugular portosystemic shunt within 72 hours of admission to the hospital (early or preventive transjugular intrahepatic portosystemic shunt [TIPS], also called preemptive TIPS) increases the proportion of high-risk patients with cirrhosis and acute variceal bleeding who survive for 1 year. However, the benefit of preemptive TIPS is less clear for patients with a Child-Pugh score of B and active bleeding (CP-B+AB). We performed an individual data meta-analysis to assess the efficacy of preemptive TIPS in these patients and identify factors associated with reduced survival of patients receiving preemptive TIPS. Methods: We searched publication databases for randomized controlled trials and observational studies comparing the effects of preemptive TIPS versus endoscopy plus nonselective beta-blockers in the specific population of high-risk patients with cirrhosis and acute variceal bleeding (CP-B+AB or Child-Pugh C, below 14 points), through December 31, 2019. We performed a meta-analysis of data from 7 studies (3 randomized controlled trials and 4 observational studies), comprising 1327 patients (310 received preemptive TIPS and 1017 received drugs plus endoscopy). We built adjusted models to evaluate risk using propensity score for baseline covariates. Multivariate Cox regression models were used to assess the factors associated with survival time. The primary endpoint was effects of preemptive TIPS versus drugs plus endoscopy on 1-year survival in the overall population as well as CP-B+AB and Child-Pugh C patients. Results: Overall, preemptive TIPS significantly increased the proportion of high-risk patients with cirrhosis and acute variceal bleeding who survived for 1 year, compared with drugs plus endoscopy (hazard ratio [HR] 0.443; 95% CI 0.323–0.607; P <.001). This effect was observed in CP-B+AB patients (HR 0.524; 95% CI 0.307–0.896; P = .018) and in patients with Child-Pugh C scores below 14 points (HR 0.374; 95% CI 0.253–0.553; P <.001). Preemptive TIPS significantly improved control of bleeding and ascites without increasing risk of hepatic encephalopathy in Child-Pugh C and CP-B+AB patients, compared with drugs plus endoscopy. Cox analysis of patients who received preemptive TIPS showed that patients could be classified into 3 categories for risk of death, based on age, serum level of creatinine, and Child-Pugh score. In each of these risk categories, preemptive TIPS increased the proportion of patients who survived for 1 year, compared with drugs plus endoscopy. Conclusions: In a meta-analysis of data from 1327 patients with cirrhosis, acute variceal bleeding, and Child-Pugh score between 10 and 13 points or CP-B+AB, preemptive TIPS increased the proportion who survived for 1 year, in both subgroups separately, compared with drugs plus endoscopy.
Original languageEnglish
Pages (from-to)193-205.e10
JournalGastroenterology
Volume160
Issue number1
DOIs
Publication statusE-pub ahead of print - Sep 24 2020

Keywords

  • AVB
  • HE
  • Liver Disease
  • Treatment

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