Reuters Health Information (2012-09-13): Early TIPS best for high-risk varices: study
Early TIPS best for high-risk varices: study
Last Updated: 2012-09-13 14:10:12 -0400 (Reuters Health)
NEW YORK (Reuters Health) - A new paper from Europe advises early use of TIPS (transjugular intrahepatic portosystemic shunting) in cirrhotic patients at high risk for variceal bleeding.
"In patients with high risk of treatment failure, the application of more aggressive, but also efficient, therapies, such as the use of early polytetrafluoroethylene (PTFE)-TIPS, improves the outcome and therefore should be the treatment of choice," Dr. Juan Carlos Garcia-Pag�n from University of Barcelona, Spain told Reuters Health in an email.
He and his colleagues reviewed data on 75 patients admitted for acute variceal bleeding and at high risk of treatment failure (i.e., Child's class C, or Child's B plus active bleeding at endoscopy despite IV vasoactive drugs).
The hospitals involved in this retrospective study had all recently participated in a randomized trial of early TIPS vs endoscopy with medical therapy.
"It is important to remark that the actuarial curves of failure to control bleeding or rebleeding and of survival in the present study were nearly identical to those of the original randomized controlled trial (RCT), supporting the beneficial effect of the early use of PTFE-covered TIPS in this high risk population out of the context of a RCT," the researchers noted in their August 31 report online in the Journal of Hepatology.
Thirty patients received endoscopic band ligation with standard medical therapy (mostly propranolol). Forty-five patients received PTFE-covered TIPS within 24 hours of the initial endoscopy, when possible, but within 72 hours in all cases. The mean follow-up was 14.6 months for the medical group and 13.1 months for the early-TIPS group.
The primary endpoint, a composite of failure to control active bleeding or to prevent clinically significant variceal rebleeding, occurred in 15 medical patients, but only three early-TIPS patients.
Six patients in the medical group died because of massive bleeding or as a result of liver or multiorgan failure. There were no deaths related to bleeding in the early-TIPS group.
The one- and two-year actuarial probabilities of the composite endpoint were 7% (both years) for the early-TIPS group, compared with 47% and 51%, respectively, for the medical group.
The one- and two-year mortality rates were also higher for the medical group (30% and 35%, respectively) than for the early-TIPS group (14% and 14%, respectively), although the differences fell short of statistical significance.
The two groups did not differ significantly in the development of hepatic encephalopathy at one year or the proportion of follow-up time patients spent in the hospital, but new or worsening ascites was significantly more common in the medical group than in the early-TIPS group (37% vs 11%; p<0.01).
"After the introduction of early-TIPS in clinical practice, we are thinking to perform a further surveillance study including a higher number of patients (more than 200) trying to identify possible groups of patients in whom maybe TIPS is also not the best answer," Dr. Garcia-Pag�n said.
J Hepatol 2012.