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Predictors of Re-bleeding and Mortality Among Patients with Refractory Variceal Bleeding Undergoing Salvage Transjugular Intrahepatic Portosystemic Shunt (TIPS)

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Abstract

Background

Transjugular intrahepatic portosystemic shunt (TIPS) has proven clinical efficacy as rescue therapy for cirrhotic patients with acute portal hypertensive bleeding who fail endoscopic treatment.

Aims

To investigate predictive factors of 6-week and 1-year mortality in patients undergoing salvage TIPS for refractory portal hypertensive bleeding.

Methods

A total of 144 consecutive patients were retrospectively evaluated. Three logistic regression multivariate models were estimated to individualize prognostic factors for 6-week and 12-month mortality. Log-rank test was used to evaluate survival according to Child–Pugh classes and Bureau’s criteria.

Results

Mean age 51 ± 10 years, 66% male, mean MELD 18.5 ± 8.3, Child–Pugh A/B/C 8%/38%/54%. TIPS failure occurred in 23(16%) patients and was associated with pre-TIPS portal pressure gradient and pre-TIPS intensive care unit stay. Six-week and 12-month mortality was 36% and 42%, respectively. Pre-TIPS intensive care unit stay, MELD, and Child–Pugh score were independently associated with mortality at 6 weeks. Independent predictors of mortality at 12 months were pre-TIPS intensive care unit stay and Child–Pugh score.

Conclusions

In this large cohort of patients undergoing salvage TIPS, MELD and Child–Pugh scores were predictive of short- and long-term mortality, respectively. Pre-TIPS intensive care unit stay was independently associated with TIPS failure and mortality at 6 weeks and 12 months. Salvage TIPS is futile in patients with Child–Pugh score of 14–15.

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Abbreviations

TIPS:

Transjugular intrahepatic portosystemic shunt

PTFE:

Polytetrafluoroethylene

MELD:

Model for end-stage liver disease

PHB:

Portal hypertensive bleeding

INR:

International normalized ratio

AST:

Aspartate aminotransferase

ALT:

Alanine aminotransferase

CPS:

Child–Pugh score

PPG:

Portal pressure gradient

RBCs:

Number of blood units transfused

ITUs:

Length of intensive care unit stay

MV:

Mechanical ventilation

HE:

Hepatic encephalopathy

OR:

Odds ratio

95% CI:

95% confidence interval

NAFLD:

Nonalcoholic fatty liver disease

AI:

Autoimmune

EV:

Esophageal varices

GV:

Gastric varices

OLT:

Orthotopic liver transplant

Na:

Sodium

PLTs:

Platelets

Hb:

Hemoglobin

WBCs:

White blood cells

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Author information

Author notes

  1. Sergio Maimone and Francesca Saffioti share first authorship.

  2. Emmanuel Tsochatzis and David Patch had equal contribution and are joint senior authors.

Authors and Affiliations

  1. UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free London NHS Foundation Trust and UCL, London, UK

    Sergio Maimone, Francesca Saffioti, Grazia Isgrò, Vincenza Calvaruso, Elias Xirouchakis, Gian Piero Guerrini, Andrew K. Burroughs, Emmanuel Tsochatzis & David Patch

  2. Division of Clinical and Molecular Hepatology, Department of Internal Medicine, University Hospital of Messina, Messina, Italy

    Sergio Maimone & Roberto Filomia

  3. Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy

    Francesca Saffioti

  4. Department of Economics, Unit of Statistical and Mathematical Sciences, University of Messina, Messina, Italy

    Angela Alibrandi

  5. Gastroenterology and Hepatology Unit, Di.Bi.M.I.S., University of Palermo, Palermo, Italy

    Vincenza Calvaruso

  6. Gastroenterology and Hepatology Department, Athens Medical P. Faliron Hospital, Athens, Greece

    Elias Xirouchakis

  7. Department of Surgery, Ravenna Hospital, Ravenna, Italy

    Gian Piero Guerrini

Authors
  1. Sergio Maimone
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  11. David Patch
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Corresponding author

Correspondence to Sergio Maimone.

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Conflict of interest

The authors who have taken part in this study do not have anything to disclose regarding funding or conflict of interest with respect to this manuscript.

Ethical approval

This was a single-center retrospective audit including consecutive patients with cirrhosis and variceal bleeding admitted at the Royal Free Hospital who underwent TIPS placement. As such, ethical approval and consent was not required.

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Maimone, S., Saffioti, F., Filomia, R. et al. Predictors of Re-bleeding and Mortality Among Patients with Refractory Variceal Bleeding Undergoing Salvage Transjugular Intrahepatic Portosystemic Shunt (TIPS). Dig Dis Sci 64, 1335–1345 (2019). https://doi.org/10.1007/s10620-018-5412-x

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