Early Transjugular Intrahepatic Portosystemic Shunt for Acute Variceal Bleeding Lowers Treatment Failure and Mortality

Abstract

A study published in The New England Journal of Medicine finds that early rescue treatment with a transjugular intrahepatic portosystemic shunt (TIPS) for cirrhosis patients who are hospitalized for acute variceal bleeding could significantly lower treatment failure and mortality. If large varices develop in the esophagus or upper stomach, patients with cirrhosis are at risk for serious bleeding due to rupture of these varices. Once varices have bled, they tend to rebleed and the probability that a patient will die from each bleeding episode is high (30%–35%). Among current practice guidelines recommended for treating patients with acute variceal bleeding are fluid resuscitation, antibiotic prophylaxis, and vasoactive drugs such as octreotide, terlipressin, or somatostatin, followed by early endoscopy and either ligation or sclerosis of the varices. Despite these measures, failure to control index bleeding occurs in 10%–20% of patients. TIPS is indicated in patients who fail to respond to β-blockers, variceal sclerotherapy, or banding. TIPS can also be considered in treating patients with ascites that does not respond to salt and fluid restriction and diuretics. Researchers with the Early TIPS Cooperative Study Group randomized 63 patients with Child class B or C cirrhosis and acute variceal bleeding who had been treated with vasoactive drugs plus endoscopic therapy, either to treatment with a polytetrafluoroethylene (PFTE)-covered stent within 72 hours of randomization (early TIPS group, 32 patients) or to continuation of vasoactive drug therapy followed by propranolol or nadolol and long-term endoscopic band ligation (EBL), with insertion of a TIPS if needed as rescue therapy (31 patients). In this multicenter international study, patients who received early TIPS had a significantly better chance of remaining free of bleeding than did those who received the standard care (97% vs 50%). The rate of survival at 6 weeks was 97% in the TIPS group as compared with 67% in the medical therapy group, as a result of reductions in rebleeding, sepsis, and liver failure. In addition, “the number of days in the intensive care unit and percentage of time in the hospital during follow-up were significantly higher in the pharmacotherapy-EBL group,” the authors state. An editorial in the same issue of the journal notes that the study “should stimulate a reevaluation of how we approach variceal bleeding in patients with Child–Pugh class B or C disease. Instead of taking a wait-and-see approach, physicians should consider the early use of TIPS with a PFTE–covered stent as first-line therapy rather than as rescue treatment if rebleeding occurred. Additional clinical trials of adequate size should be performed to confirm these findings and to examine the effect of a rapid reduction in portal pressure on disease progression in patients with cirrhosis of various causes.” See NEJM 2010;362:2370–2379, 2421–2422. Also see Hepatology 2010:51, for AASLD TIPS practice guidelines and overview.