Objectives Early placement of transjugular intrahepatic portosystemic shunt (TIPS) has been shown to improve 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 (AVB). However, early TIPS criteria may overestimate the mortality risk in a significant proportion of patients, and the survival benefit conferred by early TIPS in such patients has been questioned. Alternative criteria have been proposed to refine the criteria used to identify candidates for early TIPS. Nevertheless, the true survival benefit provided (or not) by early TIPS compared with standard treatment in the different risk categories has not been investigated in specifically designed comparative studies.
Design We collected data on 1425 consecutive patients with cirrhosis and AVB who were admitted to 12 university hospitals in China between December 2010 and June 2016. Of these, 206 patients received early TIPS, and 1219 patients received standard treatment. The Fine and Gray competing risk regression model was used to compare the outcomes between the two groups that were stratified based on the currently available risk stratification systems after adjusting for liver disease severity and other potential confounders.
Results Overall, early TIPS was associated with an 80% relative risk reduction (RRR) in mortality at 6 weeks (adjusted HR=0.20; 95% CI: 0.10 to 044; p<0.001) and 51% RRR at 1 year (adjusted HR=0.49, 95% CI: 0.32 to 0.73; p<0.001) compared with standard treatment. In stratification analyses, the RRRs in mortality did not significantly differ among the risk categories. However, the absolute risk reductions (ARRs) of mortality were more pronounced in high-risk patients. The ARRs at 6 weeks were −2.1%, −10.2% and −32.4% in Model for End-stage Liver Disease (MELD) ≤11, 12–18 and ≥19 patients and were −1.5%, −9.1% and −23.2% in Child-Pugh A, B and C patients, respectively (interaction tests, p<0.001 for both criteria). The ARRs for mortality at 1 year were −1.7%, −5.4% and −32.7% in MELD ≤11, 12–18 and ≥19 patients, respectively, and −3.6%, −5.2% and −20.3% in Child-Pugh A, B and C patients, respectively (interaction tests, p<0.001 for both criteria). After adjusting for liver disease severity and other potential confounders, a survival benefit was observed in MELD ≥19 or Child-Pugh C patients but not in MELD ≤11 or Child-Pugh A patients. In MELD 12–18 patients, a survival benefit was observed within 6 weeks but not at 1 year. In Child-Pugh B patients, a survival benefit was observed in those with active bleeding but not those without active bleeding. However, the evaluation of active bleeding was associated with a high interobserver variability. Furthermore, early TIPS was associated with a significantly reduced incidence of failure to control bleeding or rebleeding and new or worsening ascites, without increasing the risk of overt hepatic encephalopathy.
Conclusions Early TIPS was associated with improved survival in patients with MELD ≥19 or Child-Pugh C cirrhosis but not in patients with MELD ≤11 or Child-Pugh A cirrhosis. For MELD 12–18 or Child-Pugh B patients, future studies addressing optimal selection criteria for early TIPS remain highly warranted.
- liver cirrhosis
- oesophageal varices
- portal hypertension
- interventional radiology
- therapeutic endoscopy
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YL, LZ, XZ and JZ contributed equally.
Contributors Study concept and design: YL, LZ, ZY, GH. Acquisition of data: LZ, XZ, JZ, HX, ZJ, YZ, CZ, JS, PD, WR, YL, KZ, WZ, CH, JZ, QP, FM, JL, MZ, GW, JD, MS, WB, WG, QW, XY, TY, ZW, BL, XL, JY, NH, YZ, JN, KL, ZY, GH. Analysis and interpretation of data: YL, LZ, GH. Drafting of the manuscript: YL. Critical revision of the manuscript for important intellectual content: XZ, JZ, HX, ZJ, YZ, CZ, JS, PD, WR, YL, KZ, WZ, ZY, GH. Statistical analysis: YL, LZ. Administrative and material support: YN, DF.
Funding This study was supported by grants from Optimized overall project of Shaanxi province (2013KTCL03-05), Boost programme of Xijing Hospital (XJZT11Z07) and National Key Technology R&D Programme (2015BAI13B07).
Competing interests None declared.
Patient consent Obtained.
Ethics approval Ethics committees of Xijing Hospital.
Provenance and peer review Not commissioned; externally peer reviewed.
Presented at The abstract of this study was accepted as oral presentation in EASL International Liver Congress on 2018, which was held in France (PS-140).
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