Gastroenterology in critical care · Variceal bleeding
Early use of TIPS in patients with cirrhosis and variceal bleeding
| Design | Randomised controlled trial |
|---|---|
| Treatment | Early TIPS with a polytetrafluoroethylene-covered stent within 72 hours of randomisation, itself within 24 hours of admission |
| Control | Pharmacotherapy plus endoscopic band ligation |
| Population | 63 patients with cirrhosis hospitalised for acute variceal bleeding at high risk of treatment failure — Child-Pugh class C, or class B with persistent bleeding at endoscopy — all treated first with vasoactive drugs plus endoscopic therapy |
| Follow-up | Median 16 months |
| Primary endpoint | Failure to control bleeding or rebleeding |
| Result | Rebleeding or failure to control bleeding occurred in 14 patients in the pharmacotherapy plus band ligation group versus 1 patient in the early TIPS group, with significant reductions in treatment failure and mortality. |
| Secondary endpoints | Mortality, hepatic encephalopathy, transfusion requirement |
In these patients with cirrhosis who were hospitalized for acute variceal bleeding and at high risk for treatment failure, the early use of TIPS was associated with significant reductions in treatment failure and in mortality.
The trial authors, in the published abstract
A dramatic effect in a small, carefully selected high-risk group, and the basis for pre-emptive TIPS in current guidelines. The selection criteria are doing enormous work, and the trial says nothing about lower-risk bleeders.
García-Pagán JC, Caca K, Bureau C, et al. Early use of TIPS in patients with cirrhosis and variceal bleeding. N Engl J Med 2010 Jun 24;362(25):2370-9.