Z Gastroenterol 2016; 54 - P82
DOI: 10.1055/s-0036-1584060

Effectiveness of early TIPS for the treatment of acute variceal bleeding – the Viennese experience

N Göschl 1, 2, T Bucsics 1, 2, M Schoder 3, M Diermayr 1, 2, M Feldner-Busztin 1, 2, M Mandorfer 1, 2, P Schwabl 1, 2, M Cejna 4, B Angermayr 1, M Peck-Radosavljevic 1, 2, M Trauner 1, J Karner 5, F Karnel 6, T Reiberger 1, 2
  • 1Div. of Gastroenterology & Hepatology, Dept. of Internal Medicine III, Medical University of Vienna, Vienna, Austria
  • 2Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
  • 3Dept. of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
  • 4Dept. of Radiology, Landeskrankenhaus Feldkirch, Feldkirch, Austria
  • 5Dept. of Surgery, Kaiser-Franz Josef Spital, Vienna, Austria
  • 6Dept. of Radiology, Kaiser-Franz Josef Spital, Vienna, Austria

Background: Early implantation of a transjugular intrahepatic portosystemic shunt (TIPS) within 72 hours is recommended in selected cirrhotic patients with acute variceal bleeding (AVB) at high risk for treatment failure (Child-Pugh stage (CPS) C or B patients with active bleeding at endoscopy). Yet, effectiveness of early TIPS in unselected real-life cohorts has not been evaluated.

Methods: Patients with liver cirrhosis undergoing early TIPS implantation after AVB at two tertiary care hospitals in Vienna between 1994 – 2014 were retrospectively studied. In contrast to prospective early TIPS studies, we did not exclude patients with HCC outside Milan, bleeding on NSBBs, or CPS-C > 13 points.

Results: Forty-nine patients received an early TIPS within 72 hours after AVB: mean age: 55 ± 11 years, male: 33 (67%), MELD: 14.4 ± 4.4, CPS A: 2 (4.1%), B: 26 (53.1%), C: 21 (42.9%). Esophageal varices were present in all patients, 28.6% (14/49) presented additional gastric varices. Pre-TIPS mean HVPG was 24.42 ± 1.39 (available in 23, 46.9%). PTFE-covered and bare-metal stents were used in 17 (34.7%) and 32 (65.3%) patients, respectively. Six-week re-bleeding occurred in only four (8%) patients. Six-week bleeding-related mortality was 20.4% (10/49). When compared to survivors, patients who died within 6 weeks after AVB had higher INR (2.06 ± 0.31 vs. 1.52 ± 0.07; p = 0.007), higher Na-MELD score (18.2 ± 2.6 vs. 15.0 ± 0.7; p = 0.049), lower hemoglobin (8.7 ± 0.8 vs. 10.3 ± 0.3 g/dL; p = 0.038) and higher CRP (11.57 ± 6.03 vs. 2.14 ± 0.54 mg/dL; p = 0.004). Overall mortality over a median follow-up of 18.5 (IQR 66.6) months was 77.6% (38/49). Survival was significantly better in patients meeting stringent early TIPS criteria (p < 0.001), especially in those with PTFE-TIPS (58.1 vs. 10.7 months in bare stents, p = 0.029).

Conclusions: Early TIPS placement is effective to control acute variceal bleeding in a real-life cohort of patients with cirrhosis. PTFE-TIPS was superior in preventing variceal rebleeding and results in longer survival than bare stents – especially if stringent TIPS criteria are used.