Liver and Bile
Hepatology. 2024;79(3):624–35
Pre-emptive TIPS in high-risk acute variceal bleeding. An updated and revised individual patient data meta-analysis
Background and aims: A previous individual patient data meta-analysis (IPD-MA) showed that compared with drugs and 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 and active bleeding and Child-Pugh C < 14 points) with cirrhosis and acute variceal bleeding. However, the previous IPD-MA was not a 2-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. The authors performed an updated and revised IPD-MA to reassess the efficacy of p-TIPS, addressing all previous issues.
Approach and results: They included all studies from the previous IPD-MA and searched for other possible eligible publications until September 2022. They performed a 2-stage IPD-MA of data from 8 studies (4 randomized clinical trials and 4 observational). In addition, they 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. The authors identified 1389 patients (342 p-TIPS and 1047 Drugs+Endoscopy). The 2-stage IPD-MA showed that p-TIPS significantly reduced the mortality in the overall population (hazard ratio = 0.43, 95% confidence interval: 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 2-stage individual patient data meta-analysis confirms the significant survival advantage of pre-emptive transjugular intrahepatic portosystemic shunt (p-TIPS) in high-risk patients with cirrhosis and acute variceal bleeding. As a result, p-TIPS is recommended as the preferred first-choice treatment for these patients.