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Early transjugular intrahepatic portosystemic shunt for acute variceal bleeding: a systematic review and meta-analysis

  • Interventional
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Abstract

Objectives

The alleged benefit of early placement of transjugular intrahepatic portosystemic shunt (TIPS) in patients with cirrhosis and acute variceal bleeding (AVB) remains controversial. This meta-analysis was conducted to evaluate the therapeutic effect of early TIPS on cirrhotic patients with AVB.

Methods

MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases were searched for relevant literatures. Data from included studies were extracted, and random-effects meta-analyses were performed.

Results

Three randomized control trials and six observational studies involving 2878 participants were included. Compared with those undergoing standard treatment, patients undergoing early TIPS had a significantly lower all-cause mortality (RR, 0.64; 95% CI, 0.52–0.79). Furthermore, early TIPS was associated with a significantly reduced incidence of failure to control bleeding (RR, 0.15; 95% CI, 0.07–0.29) and rebleeding (RR, 0.40; 95% CI, 0.23–0.71), without increasing the risk of hepatic encephalopathy (RR, 1.13; 95% CI, 0.92–1.38). In a stratification analysis based on Child-Pugh classification, the survival benefit was observed in Child-Pugh B patients with active bleeding (RR, 0.53; 95% CI, 0.31–0.93) and Child-Pugh C patients (RR 0.55, 95% CI, 0.37–0.82), but not in low-risk patients (Child-Pugh A and Child-Pugh B without active bleeding) (RR, 0.93; 95% CI, 0.55–1.57).

Conclusion

Early TIPS is a feasible therapeutic option for cirrhotic patients with AVB, especially benefiting high-risk patients in terms of improved survival. Given the current low utilization rate in clinical practice, this study favors the placement of early TIPS in a wider range of patients with cirrhosis and AVB, especially high-risk patients.

Key Points

• Early TIPS is associated with improved survival in high-risk patients (Child-Pugh B plus active bleeding at endoscopy or Child-Pugh C 10–13) with cirrhosis and acute variceal bleeding.

• Current utilization rate of early TIPS is low in clinical practice.

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Abbreviations

AVB:

Acute variceal bleeding

CENTRAL:

Cochrane Central Register of Controlled Trials

CI:

Confidence interval

HE:

Hepatic encephalopathy

MELD:

Model for End-Stage Liver Disease

PRISMA:

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

RCT:

Randomized controlled trial

RoB:

Risk of bias

ROBINS-I:

Risk of bias of non-randomized studies of interventions

RR:

Risk ratio

TIPS:

Transjugular intrahepatic portosystemic shunt

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Funding

This work was supported by Beijing Municipal Administration of Hospitals Clinical Medicine Development of Special Funding Support (XMLX201815) and Beijing Municipal Science & Technology Commission (No. Z181100001718220).

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Authors and Affiliations

  1. Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China

    Guang-Peng Zhou, Yi-Zhou Jiang, Li-Ying Sun & Zhi-Jun Zhu

  2. Clinical Center for Pediatric Liver Transplantation, Capital Medical University, No. 95 Yong-an Road, Xi-Cheng District, Beijing, 100050, China

    Guang-Peng Zhou, Yi-Zhou Jiang, Li-Ying Sun & Zhi-Jun Zhu

  3. Intensive Care Unit, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China

    Li-Ying Sun

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  1. Guang-Peng Zhou
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Correspondence to Zhi-Jun Zhu.

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The scientific guarantor of this publication is Zhi-Jun Zhu.

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The authors report no conflicts of interest.

Statistics and biometry

The statistical methods employed in this manuscript were reviewed by Shanshan Wu, MD, PhD, from Clinical Epidemiology and EBM Unit, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China.

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Written informed consent was not required for this study because the article type is a systematic review and meta-analysis.

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Institutional Review Board approval was not required for this study because the article type is a systematic review and meta-analysis.

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Zhou, GP., Jiang, YZ., Sun, LY. et al. Early transjugular intrahepatic portosystemic shunt for acute variceal bleeding: a systematic review and meta-analysis. Eur Radiol 31, 5390–5399 (2021). https://doi.org/10.1007/s00330-020-07525-x

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  • DOI: https://doi.org/10.1007/s00330-020-07525-x

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