Early-TIPSS Placement in Patients With Variceal Bleeding
Early-TIPSS Placement in Patients With Variceal Bleeding
Background Early-TIPSS (transjugular intrahepatic portosystemic shunt) placement may improve rebleeding and reduce 1-year mortality, compared to standard management in high-risk patients with cirrhosis and variceal bleeding.
Aim To obtain external validation of this therapeutic approach.
Methods We performed a prospective study including all consecutive patients with Child–Pugh C 10–13 cirrhosis or Child–Pugh B with active bleeding at endoscopy admitted to our ICU between March 2011 and February 2013 for variceal bleeding. TIPSS were placed within 72 h after stabilisation. Patients were matched for gender, age, Child–Pugh score, MELD score and to patients from a historical cohort hospitalised before March 2011.
Results 31/128 patients with cirrhosis (77.4% men, mean age 53.2 ± 9.0 years old, MELD score 20.9 ± 6.9, Child–Pugh C: 77.4%) admitted for acute variceal bleeding between March 2011 and February 2013 (TIPSS+ group) were matched to 31 historical patients (TIPSS− group). Uncontrolled bleeding occurred in 1/31 patients in the TIPSS+ group vs. 2/31 patients in TIPSS− group (P = 0.55). The 1-year probability of being free of rebleeding was higher in the TIPSS+ group (97% vs. 51%, P < 0.001). Actuarial 1-year survival was not different between the two groups (66.8 ± 9.4% vs. 74.2 ± 7.8%, P = 0.78). Acute cardiac failure occurred more frequently in the TIPSS+ group (25.8% vs. 6.4%, P = 0.03).
Conclusions Early-TIPSS placement effectively prevents rebleeding in high-risk patients with variceal bleeding but does not significantly improve survival. This might be due to the high proportion of patients with Child–Pugh C cirrhosis in our series. Cardiac failure may play a role and must be investigated before the procedure, when possible.
Variceal bleeding is a major complication of cirrhosis, with a mortality of approximately 15% 6 weeks after haemorrhage. International guidelines include treatment with vasoactive drugs, band ligation and prophylactic antibiotics. Treatment fails in 10–15% of patients with a mortality of 80% in this group. Management of treatment failure includes repeated endoscopic treatment, transfusion and in the most severe patients, transjugular intrahepatic portosystemic shunt (TIPSS) placement as rescue therapy. Although TIPSS placement is very effective for controlling bleeding mortality after this procedure is still very high in this indication, mainly because of further deterioration of liver function.
Several studies have suggested that TIPSS placement within 72 h after admission reduces re-bleeding and improves survival in patients who are at high-risk of rebleeding. In one study, high-risk patients were defined according to hemodynamic criteria, i.e. with a hepatic venous pressure gradient (HVPG) ≥20 mmHg. TIPSS improved rebleeding as well as survival compared to standard treatment. However, in that study, the medical-treatment control group did not receive actual standard of care treatment, because endoscopic treatment included sclerotherapy. In another study, a limited number of high-risk patients (n = 63), defined according to clinical and endoscopic criteria (i.e. patients with Child–Pugh B cirrhosis and active bleeding at endoscopy or patients with Child–Pugh C cirrhosis), were included in a 3-year European multicentre trial. This study showed that early-TIPSS placement improved the probability of being free of uncontrolled bleeding or re-bleeding and also survival, with no serious adverse events. Although they are impressive, the results of this trial performed in highly selected patients must be confirmed in an external study. We began early-TIPSS placement in high-risk patients in our centre in March 2011. Therefore, we performed this prospective study to evaluate the benefit of the early-TIPSS in high-risk patients with cirrhosis and variceal bleeding for controlling bleeding, rebleeding and survival. We used a control cohort of patients who were treated before March 2011 and who received standard medical and endoscopic treatment and were matched according to demographic data, the severity of liver disease.
Abstract and Introduction
Abstract
Background Early-TIPSS (transjugular intrahepatic portosystemic shunt) placement may improve rebleeding and reduce 1-year mortality, compared to standard management in high-risk patients with cirrhosis and variceal bleeding.
Aim To obtain external validation of this therapeutic approach.
Methods We performed a prospective study including all consecutive patients with Child–Pugh C 10–13 cirrhosis or Child–Pugh B with active bleeding at endoscopy admitted to our ICU between March 2011 and February 2013 for variceal bleeding. TIPSS were placed within 72 h after stabilisation. Patients were matched for gender, age, Child–Pugh score, MELD score and to patients from a historical cohort hospitalised before March 2011.
Results 31/128 patients with cirrhosis (77.4% men, mean age 53.2 ± 9.0 years old, MELD score 20.9 ± 6.9, Child–Pugh C: 77.4%) admitted for acute variceal bleeding between March 2011 and February 2013 (TIPSS+ group) were matched to 31 historical patients (TIPSS− group). Uncontrolled bleeding occurred in 1/31 patients in the TIPSS+ group vs. 2/31 patients in TIPSS− group (P = 0.55). The 1-year probability of being free of rebleeding was higher in the TIPSS+ group (97% vs. 51%, P < 0.001). Actuarial 1-year survival was not different between the two groups (66.8 ± 9.4% vs. 74.2 ± 7.8%, P = 0.78). Acute cardiac failure occurred more frequently in the TIPSS+ group (25.8% vs. 6.4%, P = 0.03).
Conclusions Early-TIPSS placement effectively prevents rebleeding in high-risk patients with variceal bleeding but does not significantly improve survival. This might be due to the high proportion of patients with Child–Pugh C cirrhosis in our series. Cardiac failure may play a role and must be investigated before the procedure, when possible.
Introduction
Variceal bleeding is a major complication of cirrhosis, with a mortality of approximately 15% 6 weeks after haemorrhage. International guidelines include treatment with vasoactive drugs, band ligation and prophylactic antibiotics. Treatment fails in 10–15% of patients with a mortality of 80% in this group. Management of treatment failure includes repeated endoscopic treatment, transfusion and in the most severe patients, transjugular intrahepatic portosystemic shunt (TIPSS) placement as rescue therapy. Although TIPSS placement is very effective for controlling bleeding mortality after this procedure is still very high in this indication, mainly because of further deterioration of liver function.
Several studies have suggested that TIPSS placement within 72 h after admission reduces re-bleeding and improves survival in patients who are at high-risk of rebleeding. In one study, high-risk patients were defined according to hemodynamic criteria, i.e. with a hepatic venous pressure gradient (HVPG) ≥20 mmHg. TIPSS improved rebleeding as well as survival compared to standard treatment. However, in that study, the medical-treatment control group did not receive actual standard of care treatment, because endoscopic treatment included sclerotherapy. In another study, a limited number of high-risk patients (n = 63), defined according to clinical and endoscopic criteria (i.e. patients with Child–Pugh B cirrhosis and active bleeding at endoscopy or patients with Child–Pugh C cirrhosis), were included in a 3-year European multicentre trial. This study showed that early-TIPSS placement improved the probability of being free of uncontrolled bleeding or re-bleeding and also survival, with no serious adverse events. Although they are impressive, the results of this trial performed in highly selected patients must be confirmed in an external study. We began early-TIPSS placement in high-risk patients in our centre in March 2011. Therefore, we performed this prospective study to evaluate the benefit of the early-TIPSS in high-risk patients with cirrhosis and variceal bleeding for controlling bleeding, rebleeding and survival. We used a control cohort of patients who were treated before March 2011 and who received standard medical and endoscopic treatment and were matched according to demographic data, the severity of liver disease.
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