Transjugular Intrahepatic Portosystemic Shunts: Adjunctive Embolotherapy of Gastroesophageal Collateral Vessels in the Prevention of Variceal Rebleeding

Abstract

To prospectively compare rebleeding rates in patients treated with transjugular intrahepatic portosystemic shunt (TIPS) creation alone and those treated with TIPS creation combined with adjunctive embolotherapy of gastroesophageal collateral vessels. Informed consent and ethics committee approval were obtained. Between November 1991 and November 2002, the authors prospectively followed up 95 consecutive patients (61 men, 34 women; age range, 30-81 years) with variceal bleeding due to cirrhosis and portal hypertension. The patients were divided into two groups on the basis of splenoportographic findings after TIPS creation. The patients were treated with TIPS alone (group 1, 42 patients) or in combination with variceal embolotherapy (group 2, 53 patients). Embolotherapy with sclerosing agents in combination with coils was performed when varices continued to fill and the pressure gradient was more than 12 mm Hg. Rebleeding was defined as any hemorrhage necessitating a transfusion of 2 or more units of blood. Estimates for the cumulative patency, survival, and rebleeding rates were calculated by using life-table analysis; the log-rank test was used to compare the two treatment modalities. The prognostic relevance of treatment and selected variables with respect to rebleeding and survival were analyzed with multiple logistic regression. Mean follow-up time (+/- standard deviation) was 48.7 months +/- 37.8 (range, 1-127 months). The proportion of patients (Kaplan-Meier estimation) with TIPS who remained free of bleeding was 61% after 2 years and 53% after 4 years. Patients who underwent both the TIPS procedure and embolotherapy remained free of bleeding in 84% of cases after 2 years and in 81% of cases after 4 years. With respect to the rebleeding rate, the difference between the groups was statistically significant (log-rank test, P = .02). Results of multiple logistic regression analysis showed that variceal embolotherapy significantly reduced the risk of rebleeding (Wald test, P < .001). The results suggest that TIPS and adjunctive embolotherapy of gastroesophageal collateral vessels significantly lower the rebleeding rate in comparison to TIPS alone.