Pre-emptive TIPS: A New Standard for Gastric Variceal Bleeding in Cirrhosis

Managing Gastric Variceal Bleeding: Exploring Advanced Treatment Options

• Gastric variceal bleeding accounts for approximately 10% of bleeding events associated with portal hypertension and presents significant clinical challenges due to its poor prognosis.

• Current management protocols highlight variceal glue obturation (GO) as the gold standard for both controlling acute bleeding and preventing recurrence.

• However, the effectiveness of the transjugular intrahepatic portosystemic shunt (TIPS) in this scenario remains uncertain.

• This study aims to evaluate and compare the outcomes of preemptive TIPS (p-TIPS) versus a combined treatment strategy involving GO and nonselective beta blockers (NSBB) for managing acute gastric variceal bleeding.

Gastric Variceal Bleeding: Study Design

• Patients presenting with gastric variceal bleeding, excluding those with gastroesophageal varices type 1 (GOV1), who were initially stabilized with gastric obturation (GO) were randomized to one of two treatment arms: early placement of portal vein transjugular intrahepatic portosystemic shunt (p-TIPS) with a covered stent within 72 hours, or continuation of GO combined with non-selective beta-blockers (NSBB).

• The primary objective was to evaluate 1-year survival free of rebleeding (SFR). Secondary objectives included assessments of all-cause mortality at 42 days (D42) and 365 days (D365), rebleeding rates at D42 and D365, and the duration of hospital stay during the follow-up period.

• Kaplan-Meier survival estimates were used to analyze the primary endpoint, with comparisons performed using the log-rank test.

• Relative risks for SFR were calculated through a Cox proportional hazards model. The risk of rebleeding, accounting for the competing risk of death, was evaluated using the Fine & Gray subdistribution hazard model.

Comparative Outcomes of p-TIPS and GO + NSBB in Cirrhotic Patients with Gastric Variceal Bleeding

• A total of 101 cirrhotic patients (90% alcoholic, 80% male, median age 59 years, 84% Child-Pugh B/C, median MELD 14) were included. Gastric varices GOV2 (58%) were most common, followed by IGV1 (48%), with 55% of cases showing concurrent esophageal varices.

• Initial gastric obturation (GO) had complications in 20% of cases (11% bleeding, 8% glue migration). After initial GO, 47 patients received p-TIPS, while 54 continued with GO + NSBB.

• The 1-year survival free of rebleeding (SFR) was significantly higher in the p-TIPS group (73% vs. 33%; HR: 0.29, p < 0.001).

• Rebleeding rates were also lower in the p-TIPS group at 42 days (HR: 0.25, p = 0.014) and 1 year (HR: 0.20, p < 0.001). Survival rates at 1 year were similar (85% vs. 80%).

• However, 31% of the GO group required rescue TIPS, with only one death in this subgroup. Median hospital stay was shorter in the p-TIPS group (15 vs. 22 days, p = 0.10).

Key Insight

Preemptive TIPS increases one-year survival free of rebleeding threefold, positioning it as the new gold standard for managing gastric variceal bleeding in cirrhotic patients.

By - Eeshan Aggarwal

Reference: Hepatology. Volume 80, Issue S1. Abstract Supplement for The Liver Meeting by the American Association for the Study of Liver Diseases (AASLD), November 15-19, 2024, San Diego, CA.