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+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-...

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Detalles Bibliográficos
Autores: Nicoarǎ Farcǎu, Oana, Han, Guohong, Rudler, Marika, Angrisani, Debora, Monescillo, Alberto, Torres, Ferran, Casanovas, Georgina, Bosch, Jaime, Lv, Yong, Dunne, Philip D. J., Hayes, Peter C., Zhang, C., Sun, J., Thabut, , Dominique, Fan, Daiming, Hernández-Gea, Virginia, García-Pagán, Juan Carlos, Pre-emptive TIPS individual data metanalysis.group, International Variceal Bleeding Study group, Baveno Cooperation Study group
Tipo de recurso: artículo
Estado:Versión aceptada para publicación
Fecha de publicación:2023
País:España
Institución:Universidad de Barcelona
Repositorio:Dipòsit Digital de la UB
OAI Identifier:oai:diposit.ub.edu:2445/218704
Acceso en línea:https://hdl.handle.net/2445/218704
Access Level:acceso abierto
Palabra clave:Varices esofàgiques
Hemorràgia gastrointestinal
Pròtesis de Stent
Cirrosi hepàtica
Endoscòpia
Esophageal varices
Gastrointestinal hemorrhage
Stents (Surgery)
Hepatic cirrhosis
Endoscopy
Descripción
Sumario:Background and aims: A previous individual patient data meta-analysis (IPD-MA) showed that compared with drugs+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+ active bleeding and Child-Pugh C<14 points) with cirrhosis and acute variceal bleeding. However, the previous IPD-MA was not a two-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. We performed an updated and revised IPD-MA to reassess the efficacy of p-TIPS, addressing all previous issues. Approach and results: We included all studies from the previous IPD-MA and searched for other possible eligible publications until September 2022. We performed a two-stage IPD-MA of data from 8 studies (4 randomized clinical trials and 4 observational). In addition, we 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.We identified 1389 patients (342 p-TIPS and 1047 Drugs+Endoscopy). The two-stage IPD-MA showed that p-TIPS significantly reduced the mortality in the overall population (HR=0·43, 95% CI: 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 two-stage IPD-MA confirms the significant survival advantage of p-TIPS in high-risk patients with cirrhosis and acute variceal bleeding. As a result, we recommend p-TIPS as the preferred first-choice treatment for these patients.

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