Transjugular intrahepatic portosystemic shunt (TIPS) placement at index portal hypertensive decompensation (anticipant TIPS) in cirrhosis and the role of early intervention in variceal bleeding and ascites

Sasidharan Rajesh; Cyriac Abby Philips; Somsharan Shankerappa Betgeri; Tom George; Rizwan Ahamed; Meera Mohanan; Philip Augustine

doi:10.1007/s12664-021-01179-3

Transjugular intrahepatic portosystemic shunt (TIPS) placement at index portal hypertensive decompensation (anticipant TIPS) in cirrhosis and the role of early intervention in variceal bleeding and ascites

Indian J Gastroenterol. 2021 Aug;40(4):361-372. doi: 10.1007/s12664-021-01179-3. Epub 2021 Jul 29.

Authors

Sasidharan Rajesh¹, Cyriac Abby Philips^{2

3}, Somsharan Shankerappa Betgeri⁴, Tom George¹, Rizwan Ahamed⁵, Meera Mohanan⁶, Philip Augustine⁵

Affiliations

¹ Interventional Radiology, Ernakulam Medical Center, Kochi 682 028, India.
² The Liver Unit and Monarch Liver Lab, Ernakulam Medical Center, Kochi 682 028, India. abbyphilips@gmail.com.
³ Philip Augustine Associates, Symphony, AMRA-15, Automobile Road, Palarivattom, Kochi, 682 025, India. abbyphilips@gmail.com.
⁴ Interventional Radiology, Caritas Hospital, Kottayam 686 630, India.
⁵ Gastroenterology and Advanced G.I. Endoscopy, Ernakulam Medical Center, Kochi 682 028, India.
⁶ Department of Anaesthesia and Critical Care, Ernakulam Medical Center, Kochi 682 028, India.

PMID: 34324168
DOI: 10.1007/s12664-021-01179-3

Abstract

Background: Transjugular intrahepatic portosystemic shunt (TIPS) placement improves survival in patients with refractory/recurrent acute variceal bleeding (RAVB) and refractory ascites/hydrothorax. Recently, early TIPS was shown to reduce rebleeding and improve survival compared to the conventional TIPS. We aimed to study outcomes in patients with cirrhosis undergoing TIPS at first significant portal hypertensive (PHT) decompensation (termed anticipant TIPS) compared to those undergoing TIPS for recurrent or persistent PHT complications (conventional) and compared the former to matched controls on standard medical management (SMT).

Methods: We retrospectively analyzed the clinical, biochemical, and liver disease severity parameters and survival at baseline and post-intervention in cirrhosis patients at two major hepatobiliary intervention centers undergoing anticipant (n = 27) or conventional TIPS (n = 30) and compared the former group to matched historical controls on SMT (n = 35).

Results: Baseline parameters were comparable between both the groups, including the Child-Pugh class and model for end-stage liver disease (MELD) scores. Length of stay in the intensive care unit, post-procedure admission rates, and sepsis events were higher among patients undergoing conventional TIPS (p < 0.05). Post-TIPS, at 1 year, overall and sub-grouped survivals were better in patients undergoing anticipant TIPS. On further sub-group analysis, based on the PHT events and stratified based on Child-Pugh and MELD scores, a higher proportion of patients survived after anticipant TIPS at 1 year. Compared to SMT, patients undergoing anticipant TIPS had significantly lesser hospitalizations, recurrence of varices, and ascites at 1 year, reducing hospital visits and financial burden.

Conclusions: Anticipant TIPS at the first significant PHT event could improve liver-related events and survival compared to standard medical management and conventional TIPS, respectively.

Keywords: Acute kidney injury; Early TIPS; Hepatic encephalopathy; Hydrothorax; Liver failure; Pre-emptive TIPS; Refractory ascites; Rescue TIPS; Upper GI bleeding.

MeSH terms

Ascites* / etiology
Ascites* / therapy
End Stage Liver Disease*
Esophageal and Gastric Varices* / etiology
Esophageal and Gastric Varices* / surgery
Gastrointestinal Hemorrhage* / etiology
Humans
Liver Cirrhosis* / complications
Portasystemic Shunt, Transjugular Intrahepatic*
Retrospective Studies
Severity of Illness Index
Treatment Outcome
Varicose Veins*