S1139 Transjugular Intrahepatic Portosystemic Shunt vs Balloon-Occluded Transvenous Obliteration for the Management of Non-Esophagogastric Varices

Abstract

INTRODUCTION: There are few options for bleeding rectal or peristomal varices in patients unable to undergo transjugular intrahepatic portosystemic shunt (TIPS). There is extensive experience with balloon-occluded antegrade or retrograde transvenous obliteration (BA-RTO) of gastric and esophageal (GE) varices. However, there is a paucity of data regarding the use of BA-RTO for the management of non-esophagogastric (Non-GE) varices. In this study, we assess the outcomes of patients with bleeding Non-GE varices managed by BA-RTO vs. TIPS. METHODS: Patients undergoing TIPS vs. BA-RTO procedures for Non-GE varices at our liver center were compared for demographics, MELD-Na labs prior to and following procedure, rebleeding, frequency of paracentesis and hepatic encephalopathy and mortality. RESULTS: 14 patients underwent procedures for bleeding Non-EV varices. Nine patients had rectal varices, four peristomal and one duodenal. Six patients undergoing BA-RTO were compared to eight patients undergoing TIPS. Of the BA-RTO patients, 5 had BATO and 1 BRTO. There were no differences in age, gender, race or cause of liver disease. In the BA-RTO groups, mean MELD-Na prior to procedures was 23.3 ± 9.4 declining to 20.0 ± 10.4 and 18.0 ± 4.2 at 30 and 90 days after procedure. TIPS patients had a MELD-Na prior to procedure of 18.5 ± 6.1 increasing to 21.7 ± 5.5 and 24.0 ± 7.5.4. Of the BA-RTO patients, 4 were felt to be too ill for TIPS and, of these, 2 died within 90 days: 1 from uncontrolled bleeding and 1 from sepsis. 2 of 8 TIPs patients died within 90 days with 1 from uncontrolled bleeding. Rebleeding rates were 16.7 for BA-RTO vs. 12.5% for TIPS (P = 1.00) and no procedures were repeated. Comparing BA-RTO to TIPS, median length of stay was 14.5 ± 9.8 vs. 7.8 ± 7.5 (P = 0.14), paras 90 days prior and after procedure were 3.5 ± 4.5 vs. 0.0 ± 0.0 (P = 0.018) and 3.0 ± 4.6 vs. 0.0 ± 0.0 (P = 0.028). There were no differences in hepatic encephalopathy in the 90 days before and after the procedure (66.7 vs. 50% and 33.3 vs. 25.0%). CONCLUSION: TIPS remains an excellent option for bleeding Non-EV varices. Despite the fact that BA-RTO patients were more ill and typically not candidates for TIPS, BA-RTO was an excellent alternative with non-inferiority in terms of rebleeding and mortality. Patients undergoing BA-RTO had a decline in MELD score whereas TIPS patients had an increase. Either modality should be considered early before patients are increasingly ill.Figure 1.: Overall survival between groups with three patients removed Note: Patient which had the event of interest at 3000 days was censored at 2000 days.