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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

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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.

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Authors and Affiliations

  1. Interventional Radiology, Ernakulam Medical Center, Kochi 682 028, India

    Sasidharan Rajesh & Tom George

  2. The Liver Unit and Monarch Liver Lab, Ernakulam Medical Center, Kochi 682 028, India

    Cyriac Abby Philips

  3. Philip Augustine Associates, Symphony, AMRA-15, Automobile Road, Palarivattom, Kochi, 682 025, India

    Cyriac Abby Philips

  4. Interventional Radiology, Caritas Hospital, Kottayam 686 630, India

    Somsharan Shankerappa Betgeri

  5. Gastroenterology and Advanced G.I. Endoscopy, Ernakulam Medical Center, Kochi 682 028, India

    Rizwan Ahamed & Philip Augustine

  6. Department of Anaesthesia and Critical Care, Ernakulam Medical Center, Kochi 682 028, India

    Meera Mohanan

Authors
  1. Sasidharan Rajesh
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  2. Cyriac Abby Philips
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  3. Somsharan Shankerappa Betgeri
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  4. Tom George
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  5. Rizwan Ahamed
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  7. Philip Augustine
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Contributions

CAP and SR designed the study; SR, TG, and SSB collected data; CAP, PA, and RA analyzed data; CAP, SR, TG, and RA wrote the manuscript; MM, PA, and RA critically revised the manuscript; all authors approved the final version

Corresponding author

Correspondence to Cyriac Abby Philips.

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Conflict of interest

SR, CAP, SSB, TG, RA, MM, and PA   declare that they have no conflict of interest.

Ethics statement

The study was performed conforming to the Helsinki declaration of 1975, as revised in 2000 and 2008 concerning human and animal rights, and the authors followed the policy concerning informed consent as shown on Springer.com.

Disclaimer

The authors are solely responsible for the data and the contents of the paper. In no way, the Honorary Editor-in-Chief, Editorial Board Members, the Indian Society of Gastroenterology or the printer/publishers are responsible for the results/findings and content of this article.

Disclosures

This study was presented at the Plenary Session of the Asia-Pacific Digestive Week 2019, held at Kolkata, India, in December 2019 and was presented as Lecture Oral at the Digestive Diseases Week 2020 held in May 2020 at Chicago, USA.

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Supplementary Information

ESM 1

(DOCX 14 kb)

Supplementary Fig. 1

Patient screening and inclusion in the study (PNG 1099 kb)

High resolution image (TIF 204 kb)

Supplementary Fig. 2

Pertinent patient characteristics and liver disease severity between groups from baseline at end of 1-year follow-up (PNG 275 kb)

High resolution image (TIF 1485 kb)

Supplementary Fig. 3

Proportion of patients surviving and dying at end of study follow-up, grouped according type of TIPS procedure performed and sub grouped according to Child-Pugh and MELD scores (PNG 670 kb)

High resolution image (TIF 2848 kb)

Supplementary Fig. 4

Kaplan-Meier analysis of overall survival and survival sub grouped according to portal hypertensive complications between patients undergoing early TIPS compared to those on standard medical management (PNG 260 kb)

High resolution image (TIF 1205 kb)

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Rajesh, S., Philips, C.A., Betgeri, S.S. et al. 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 40, 361–372 (2021). https://doi.org/10.1007/s12664-021-01179-3

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  • DOI: https://doi.org/10.1007/s12664-021-01179-3

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