Effectiveness of Early TIPS Implantation vs. Late TIPS vs. Standard Endoscopic Treatment for Acute Variceal Bleeding in Patients with Liver Cirrhosis

TA Bucsics; M Schoder; M Mandorfer; P Schwabl; F Riedl; D Bauer; M Trauner; M Peck-Radosavljevic; J Karner; F Karnel; T Reiberger

doi:10.1055/s-0038-1654604

Zeitschrift für Gastroenterologie, Table of Contents

Z Gastroenterol 2018; 56(05): e29
DOI: 10.1055/s-0038-1654604

VORTRÄGE

Georg Thieme Verlag KG Stuttgart · New York

Effectiveness of Early TIPS Implantation vs. Late TIPS vs. Standard Endoscopic Treatment for Acute Variceal Bleeding in Patients with Liver Cirrhosis

TA Bucsics

¹Medical University of Vienna/Dpt. of Internal Medicine III, Vienna, Austria

,

M Schoder

²Medical University of Vienna/Dpt. of Biomedical Imaging and Image-Guided Therapy, Vienna, Austria

,

M Mandorfer

¹Medical University of Vienna/Dpt. of Internal Medicine III, Vienna, Austria

,

P Schwabl

¹Medical University of Vienna/Dpt. of Internal Medicine III, Vienna, Austria

,

F Riedl

¹Medical University of Vienna/Dpt. of Internal Medicine III, Vienna, Austria

,

D Bauer

¹Medical University of Vienna/Dpt. of Internal Medicine III, Vienna, Austria

,

M Trauner

¹Medical University of Vienna/Dpt. of Internal Medicine III, Vienna, Austria

,

M Peck-Radosavljevic

³Klinikum Klagenfurt am Wörthersee, Klagenfurt, Austria

,

J Karner

⁴Kaiser-Franz-Josef-Spital/Dpt. of Surgery, Vienna, Austria

,

F Karnel

⁵Kaiser-Franz-Josef-Spital/Dpt. of Radiology, Vienna, Austria

,

T Reiberger

¹Medical University of Vienna/Dpt. of Internal Medicine III, Vienna, Austria

› Author Affiliations

Abstract

Full Text

Introduction:

Early implantation of a transjugular intrahepatic portosystemic shunt (TIPS) within 72h is recommended for the treatment of acute variceal bleeding (AVB) in selected patients. However, early TIPS may not always be available.

Methods:

We retrospectively evaluated outcomes (bleeding, mortality) after “early TIPS” (< 72 hours, N = 36) to TIPS implanted at a later time point (72h-28 days after AVB, “delayed TIPS”, N = 68) and to combined endoscopic/nonselective betablocker treatment (“EBL/NSBB”, N = 33).

Results:

Patients in the “EBL/NSBB” control group (mean age: 60.5 ± 10.9 years) were older than TIPS patients (early TIPS: 54.3 ± 9.3 years, p = 0.013; delayed TIPS: 52.2 ± 10.0 years; p = 0.001). Baseline MELD scores were comparable between groups (“early TIPS”: 12.8, 11.7 – 15.7 vs. “delayed TIPS”: median 12.4, IQR: 10.4 – 15.0; p = 0.242 vs. “EBL/NSBB” controls: 13.6, 10.5 – 16.7, p = 0.687). TIPS implantation was generally associated with low early re-bleeding (early TIPS: 8.3%; delayed TIPS 2.9%, p = 0.338) and low overall re-bleeding rates (early TIPS: 30.6%; delayed TIPS: 33.8%, p = 0.735) when compared to “EBL/NSBB” controls (36.4% and 51.5%, respectively, p = 0.005 and p = 0.077 vs. “early TIPS”). Similarly, bleeding-related mortality within 6 weeks (early TIPS: 16.7%; delayed TIPS: 8.8%) and mortality at one-year (early TIPS: 30.6%, delayed TIPS: 13.2%) appeared lower with TIPS as compared to “EBL/NSBB” controls (bleeding-related mortality: 35.7%, p = 0.081 vs. early TIPS and p = 0.003 vs. delayed TIPS; 1-year mortality: 53.6%, p = 0.063 vs. early TIPS and p < 0.001 vs. delayed TIPS). After adjusting for age and MELD in Cox regression analysis, both “early TIPS” (OR: 0.524, p = 0.041) and “delayed” TIPS (OR 0.548, p = 0.021) were effective in reducing mortality after AVB.

Conclusions:

TIPS implantation effectively prevents variceal re-bleeding and reduces mortality in selected patients after AVB as compared to EBL/NSBB combination therapy – even if placed after 72h. We thus recommend TIPS implantation for AVB in patients who fulfil “early TIPS” criteria even when “early TIPS” implantation within 72h is not possible.