Letter to the Editor: Effects of Early Placement of Transjugular Portosystemic Shunts in Patients With High-Risk Acute Variceal Bleeding: A Meta-analysis of Individual Patient Data

Abstract

It is with great interest that we read the meta-analysis by Nicoară-Farcău and colleagues1Nicoară-Farcău O. et al.Gastroenterology. 2021; 160: 193-205.e10Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar on preemptive transjugular intrahepatic portosystemic shunt (p-TIPS) in high-risk patients with cirrhosis and variceal bleeding. Patients with Child-Pugh (CP) B and active bleeding or patients with CP-C below 14 points showed an improved 1-year survival with p-TIPS as compared with the combination of endoscopic treatment and nonselective beta-blockers alone (79% vs 62%, P < .001). Although the authors confirmed the results of prior meta-analyses, their approach to use individual patient data is novel and an important methodological strength. It allowed the identification of age >55 years, CP score >11 points, and creatinine ≥1.3 mg/dL as independent risk factors for post-TIPS mortality, and these were subsequently used to assess the survival benefit of p-TIPS in stratified subgroups. Importantly, it was shown that survival was statistically significantly better with p-TIPS for all risk groups. These results highlight the need for an increased awareness of the benefit of p-TIPS in patients with cirrhosis and variceal bleeding, and perhaps for the need of securing access to TIPS for a wider group of patients. As shown recently, p-TIPS is underused in daily practice, as only 7% to 13% of eligible patients actually underwent this procedure.2Hernandez-Gea V. et al.Hepatology. 2019; 69: 282-293Crossref PubMed Scopus (2) Google Scholar,3Thabut D. et al.J Hepatol. 2017; 68: 73-81Abstract Full Text Full Text PDF PubMed Scopus (65) Google Scholar Delayed implementation may be due to logistics, but also reluctance among physicians out of fear for unfavorable outcome. Indeed, hepatic encephalopathy (HE) remains an important complication of TIPS placement, which occurs in 15% to 40% of patients.4Trebicka J. J Hepatol. 2017; 66: 442-450Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar Even though evidence for effective preventive strategies for post-TIPS encephalopathy is surfacing, HE is associated with a reduced health-related quality of life, increased health care resource use, and impaired overall survival in patients with cirrhosis.5Bureau C. et al.Hepatology. 2019; 70: 10AGoogle Scholar,6Stewart C.A. et al.Liver Transpl. 2007; 13: 1366-1371Crossref PubMed Scopus (202) Google Scholar In our experience, the risk assessment of HE after TIPS can be clinically challenging, and this also applies to the risk of cardiac decompensation in some patients, especially in the acute setting.7Billey C. et al.Hepatology. 2019; 70: 1928-1941Crossref PubMed Scopus (37) Google Scholar Thus, seeing that the higher risk of HE among patients treated with p-TIPS vs endoscopy and nonselective beta-blockers was not found to be statistically significant was relevant (Inverse Probability of Treatment Weights–adjusted Hazard Ratio 1.078, P = .553). To what extent selection bias, coming from the inclusion of patients from expert centers, and presence/absence of HE pre-TIPS influenced this positive outcome remains difficult to ascertain. To fully appraise the risk-benefit ratio of p-TIPS in real-life, more data are needed on the severity of pre- and post-TIPS HE and other complications following TIPS, such as cardiac decompensation. Careful patient selection for p-TIPS therefore is needed. With the acquisition of individual patient data, the authors may now have a great tool to explore these questions further and to elaborate on the balance between the absolute survival benefit and the risk and impact of TIPS-related morbidities. For example, can they identify risk factors for development of post-TIPS HE? And can they ultimately select patients in whom the benefits do not outweigh the risks? All attempts to refine patient selection could be worthwhile, as we foresee a new standard of care emerging for a wider group of patients than was previously the case. Effects of Early Placement of Transjugular Portosystemic Shunts in Patients With High-Risk Acute Variceal Bleeding: a Meta-analysis of Individual Patient DataGastroenterologyVol. 160Issue 1PreviewCompared with drugs plus endoscopy, placement of transjugular portosystemic shunt within 72 hours of admission to the hospital (early or preventive transjugular intrahepatic portosystemic shunt [TIPS], also called preemptive TIPS) increases the proportion of high-risk patients with cirrhosis and acute variceal bleeding who survive for 1 year. However, the benefit of preemptive TIPS is less clear for patients with a Child-Pugh score of B and active bleeding (CP-B+AB). We performed an individual data meta-analysis to assess the efficacy of preemptive TIPS in these patients and identify factors associated with reduced survival of patients receiving preemptive TIPS. Full-Text PDF