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

Abstract

Transjugular-intrahepatic portosystemic-shunt (TIPS) and SX-Ella stentDanis (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. Cirrhotic patients with refractory variceal bleed (n = 121) who underwent rescue TIPS within 24-h (n = 66) were included. Their early rebleed (upto 42days) 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/8-24h) were also analyzed. 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 8-24h 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 gradientat6-weeksand1-year was comparable betweensurvivorsandnon-survivors. Active bleeding at endoscopy [HR = 11.8; 95% CI2.96-47.53], 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 > 64.5mmHg [HR = 0.8; 95% CI 0.75-0.92] independently predicted 6-week mortality in rescue TIPS-group. 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.