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Hepatology

Publication date: 2019-01-01
Volume: 69 Pages: 282 - 293
Publisher: Wiley

Author:

Hernandez-Gea, Virginia
Procopet, Bogdan ; Giraldez, Alvaro ; Amitrano, Lucio ; Villanueva, Candid ; Thabut, Dominique ; Ibanez-Samaniego, Luis ; Silva-Junior, Gilberto ; Martinez, Javier ; Genesca, Joan ; Bureau, Christophe ; Trebicka, Jonel ; Llop, Elba ; Laleman, Wim ; Maria Palazon, Jose ; Castellote, Jose ; Rodrigues, Susana ; Gluud, Lise L ; Ferreira, Carlos Noronha ; Barcelo, Rafael ; Canete, Nuria ; Rodriguez, Manuel ; Ferlitsch, Arnulf ; Luis Mundi, Jose ; Gronbaek, Henning ; Hernandez-Guerra, Manuel ; Sassatelli, Romano ; Dell'Era, Alessandra ; Senzolo, Marco ; Abraldes, Juan G ; Romero-Gomez, Manuel ; Zipprich, Alexander ; Casas, Meritxell ; Masnou, Helena ; Primignani, Massimo ; Krag, Aleksander ; Nevens, Frederik ; Luis Calleja, Jose ; Jansen, Christian ; Robic, Marie Angele ; Conejo, Irene ; Catalina, Maria-Vega ; Albillos, Agustin ; Rudler, Marika ; Alvarado, Edilmar ; Guardascione, Maria Anna ; Tantau, Marcel ; Bosch, Jaime ; Torres, Ferran ; Carlos Garcia-Pagan, Juan ; Fischer, Petra ; Stefanescu, Horia ; Pop, Andreea ; Laursen, Stig B ; Turon, Fanny ; Baiges, Anna ; Berbel, Claudia ; Cerda, Eira ; Tellez, Luis ; Allegretti, Giulia ; Macedo, Guilherme ; Haldrup, David ; Santos, Patricia ; Moura, Miguel ; Reis, Daniela ; Meireles, Liliane ; Sousa, Patricia ; Alexandrino, Paula ; Navascues, Carmen ; Augustin, Salvador ; La Mura, Vincenzo ; Banares, Rafael ; Diaz, Raquel ; Gomez, Marta Lopez ; Ripoll, Cristina

Keywords:

Science & Technology, Life Sciences & Biomedicine, Gastroenterology & Hepatology, INTRAHEPATIC PORTOSYSTEMIC SHUNT, AMERICAN ASSOCIATION, PRACTICE GUIDELINE, LIVER-DISEASES, CIRRHOSIS, MORTALITY, EPIDEMIOLOGY, PLACEMENT, SURVIVAL, PRESSURE, Adult, Esophageal and Gastric Varices, Female, Gastrointestinal Hemorrhage, Humans, Male, Middle Aged, Portasystemic Shunt, Transjugular Intrahepatic, Prospective Studies, Recurrence, Risk Assessment, Secondary Prevention, Treatment Failure, Treatment Outcome, International Variceal Bleeding Observational Study Group and Baveno Cooperation, 1101 Medical Biochemistry and Metabolomics, 1103 Clinical Sciences, 1107 Immunology, 3202 Clinical sciences, 3204 Immunology

Abstract:

Patients admitted with acute variceal bleeding (AVB) and Child-Pugh C score (CP-C) or Child-Pugh B plus active bleeding at endoscopy (CP-B+AB) are at high risk for treatment failure, rebleeding, and mortality. A preemptive transjugular intrahepatic portosystemic shunt (p-TIPS) has been shown to improve survival in these patients, but its use in clinical practice has been challenged and not routinely incorporated. The present study aimed to further validate the role of preemptive TIPS in a large number of high-risk patients. This multicenter, international, observational study included 671 patients from 34 centers admitted for AVB and high risk of treatment failure. Patients were managed according to current guidelines, and use of drugs and endoscopic therapy (D+E) or p-TIPS was based on individual center policy. p-TIPS in the setting of AVB is associated with a lower mortality in CP-C patients compared with D+E (1 year mortality 22% vs. 47% in D+E group; P = 0.002). Mortality rate in CP-B+AB patients was low, and p-TIPS did not improve it. In CP-C and CP-B+AB patients, p-TIPS reduced treatment failure and rebleeding (1-year cumulative incidence function probability of remaining free of the composite endpoint: 92% vs. 74% in the D+E group; P = 0.017) and development of de novo or worsening of previous ascites without increasing rates of hepatic encephalopathy. Conclusion: p-TIPS must be the treatment of choice in CP-C patients with AVB. Because of the strong benefit in preventing further bleeding and ascites, p-TIPS could be a good treatment strategy for CP-B+AB patients.