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Accepted version

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2023-10-02

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Please use this identifier to cite or link to this item: https://hdl.handle.net/2445/218704

Pre-emptive TIPS in high-risk acute variceal bleeding. An updated and revised individual patient data meta-analysis

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https://doi.org/10.1097/HEP.0000000000000613

Abstract

Background and aims: A previous individual patient data meta-analysis (IPD-MA) showed that compared with drugs+endoscopy, the placement of transjugular portosystemic shunt within 72 hours of admission (pre-emptive transjugular intrahepatic portosystemic shunt: p-TIPS) increases the survival of high-risk patients (Child-Pugh B+ active bleeding and Child-Pugh C<14 points) with cirrhosis and acute variceal bleeding. However, the previous IPD-MA was not a two-stage meta-analysis, did not consider the potential risk of selection bias of observational studies, and did not include the most recent randomized clinical trial. We performed an updated and revised IPD-MA to reassess the efficacy of p-TIPS, addressing all previous issues. Approach and results: We included all studies from the previous IPD-MA and searched for other possible eligible publications until September 2022. We performed a two-stage IPD-MA of data from 8 studies (4 randomized clinical trials and 4 observational). In addition, we performed a sensitivity analysis excluding those patients dying up to the first 72 hours after admission in the Drugs+Endoscopy arms of the 4 observational studies. The primary end point was the effects of p-TIPS versus Drugs+Endoscopy on 1-year survival.We identified 1389 patients (342 p-TIPS and 1047 Drugs+Endoscopy). The two-stage IPD-MA showed that p-TIPS significantly reduced the mortality in the overall population (HR=0·43, 95% CI: 0.32-0.60, p <0.001. This effect was observed in both subgroups of patients with Child-Pugh. The sensitivity analysis confirmed the survival benefit of p-TIPS. Conclusions: The updated two-stage IPD-MA confirms the significant survival advantage of p-TIPS in high-risk patients with cirrhosis and acute variceal bleeding. As a result, we recommend p-TIPS as the preferred first-choice treatment for these patients.

Subject

Varices esofàgiques, Hemorràgia gastrointestinal, Pròtesis de Stent, Cirrosi hepàtica, Endoscòpia

Subject (English)

Esophageal varices, Gastrointestinal hemorrhage, Stents (Surgery), Hepatic cirrhosis, Endoscopy

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Articles publicats en revistes (Medicina)
Articles publicats en revistes (IDIBAPS: Institut d'investigacions Biomèdiques August Pi i Sunyer)

Citation

NICOARǍ FARCǍU, Oana, et al. Pre-emptive TIPS in high-risk acute variceal bleeding. An updated and revised individual patient data meta-analysis. Hepatology. 2023. Vol. 79, num. 3, pags. 624-635. ISSN 0270-9139. [consulted: 19 of August of 2026]. Available at: https://hdl.handle.net/2445/218704

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