Preemptive-TIPS improves outcome in high-risk variceal bleeding : An observational study

Objective 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. Preemptive TIPS (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. Design Multicenter, international, observational study including 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 preemptive TIPS (p‐TIPS) was based on individual center policy. Results p‐TIPS in the setting of AVB is associated with a lower mortality in Child C patients compared to 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 reduces treatment failure and rebleeding (1 year CIF‐probability of remaining free of the composite endpoint: 92% vs 74% in the D+E group; P=0.017), 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. Due to the strong benefit in preventing further bleeding and ascites, p‐TIPS could be a good treatment strategy for CP‐B+AB patients.