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Emergent rescue transjugular intrahepatic portosystemic shunt within 8 h improves survival in patients with refractory variceal bleed

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Abstract

Background

Transjugular-intrahepatic portosystemic-shunt (TIPS) and SX-Ella stent Danis (DE stent) are available rescue therapies for refractory variceal bleeding in cirrhosis. Any delay in appropriate therapy is associated with high mortality. Determining the best timing for rescue TIPS is crucial and largely unknown.

Methods

Cirrhotic patients with refractory variceal bleed (n = 121) who underwent rescue TIPS within 24-h (n = 66) were included. Their early rebleed (upto 42 days) rate, 6-week and 1-year survival were compared with matched patients who underwent rescue DE stent (n = 55). Outcomes based on timing of TIPS (within 8-h/8-24 h) were also analyzed.

Results

At baseline, patients who received rescue DE stent were sicker with higher MELD score (27.6 ± 8.3 vs. 22.3 ± 7.9; p = 0.001), active bleeding at endoscopy (54.5% vs. 34.8%; p = 0.03) compared to TIPS-group. After propensity score matching, adjusting for MELD-Na score and non-bleed complications, DE patients (n = 34) had higher mortality at 6-week (17/34; 50%) and 1-year (29/34; 85.3%) compared to TIPS-group (20.6% and 38.2%, respectively; both p < 0.02), with higher rebleeding rate (10/34; 29.4% vs. 1/34; 2.9%, p = 0.003). Rescue TIPS placed within 8-h compared with 8–24 h had lower 6-week (48.6% vs. 12.9%; p = 0.003) and 1-year mortality (62.9% vs. 16.1%, p = 0.001) despite comparable rebleed rates (2/31; 6.5% vs. 2/35;5.7%; p = 0.90). Post-TIPS Portal pressure gradient at 6-weeks and 1-year was comparable between survivors and non-survivors. Active bleeding at endoscopy [HR = 11.8; 95% CI 2.96–47.53], presence of AKI [HR = 5.8; 95% CI 1.92–17.41], MELD-Na > 24 [HR = 1.1; 95% CI 1.0–1.17], mean arterial pressure > 64.5 mmHg [HR = 0.8; 95% CI 0.75–0.92] independently predicted 6-week mortality in rescue TIPS-group.

Conclusions

Rescue TIPS placement preferably within 8-h of refractory variceal bleed improves short- and long-term survival. It provides better outcome than DE stent for control of bleeding and prevention of rebleeding, even in patients with high MELD-Na score.

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Data availability

All data generated or analysed during this study are included in this published article (and its supplementary information files).

Abbreviations

AVB:

Acute variceal bleeding

DE:

SX-Ella stent Danis

TIPS:

Transjugular intrahepatic portosystemic shunt

AKI:

Acute kidney injury

CT:

Computed tomography

MAP:

Mean arterial pressure

HVPG:

Hepatic venous pressure gradient

SEMS:

Self-expandable metallic stent

CTP:

Child–Turcotte–Pugh score

MELD-Na:

Model for End Stage Liver disease sodium score

HE:

Hepatic encephalopathy

PRBC:

Packed red blood cell

PPG:

Portal pressure gradient

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Author notes

  1. Amar Mukund, Sudhir Vasistha and Ankur Jindal are joint first co-authors.

Authors and Affiliations

  1. Department of Intervention Radiology, Institute of Liver and Biliary Sciences, New Delhi, India

    Amar Mukund, Sudhir Vasistha & Yashwant Patidar

  2. Department of Hepatology, Institute of Liver and Biliary Sciences, D – 1, Vasant Kunj, New Delhi, 110070, India

    Ankur Jindal & Shiv K. Sarin

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  1. Amar Mukund
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  2. Sudhir Vasistha
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Contributions

AM: conceptualization, review and original draft preparation (supporting), analysis (equal), editing of manuscript (equal); SV, AJ: investigation (lead), analysis (equal) and original draft preparation (lead); YP: project administration, original draft preparation (supporting); SKS: conceptualization (lead), review and editing of manuscript (equal).

Corresponding author

Correspondence to Shiv K. Sarin.

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Conflict of interest

Amar Mukund, Sudhir Vasistha, Ankur Jindal, Yashwant Patidar and Shiv K. Sarin have no conflict of interest to declare.

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Mukund, A., Vasistha, S., Jindal, A. et al. Emergent rescue transjugular intrahepatic portosystemic shunt within 8 h improves survival in patients with refractory variceal bleed. Hepatol Int 17, 954–966 (2023). https://doi.org/10.1007/s12072-022-10479-5

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