Role of early transjugular intrahepatic portosystemic stent-shunt in acute variceal bleeding: An update of the evidence and future directions

Table 3 Early transjugular intrahepatic portosystemic stent-shunt in acute variceal bleeding: Key meta-analyses

Ref.	Design	Results	Comments
Deltenre et al[43]	4 studies (2 RCTs[12,39] and 2 Observational[49,52] ) included.	e-TIPSS was associated with fewer deaths [odds ratio (OR) = 0.38, P = 0.02], and with lower rates of bleeding (OR = 0.08, 95%CI: 0.04–0.17, P < 0.001) within 1 year when compared to SOC, without increase in incidence of encephalopathy (OR = 0.84, 95% CI: 0.50–1.42, P = 0.5).	There was moderate heterogeneity between studies. No significant difference in mortality was observed between Child–Pugh B and C patients. This could be explained by inclusion of sicker patients (C-P score < 14) in Rudler et al[52] study.
Nicoară-Farcău et al[47]	Individual data meta-analysis from 7 studies (3 RCTs[12,39,44] and 4 observational studies[45,49,51,52]), comprising 1327 patients (310 received e-TIPSS, 1017 received SOC (drugs + endoscopic treatment).	Overall, e- TIPSS significantly increased 1- year survival compared with SOC [hazard ratio (HR) 0.443; P < 0.001]. e-TIPSS significantly reduced the risk of failure to control bleeding/preventing variceal rebleeding (HR = 0.338; P < 0.001) and ascites without increasing risk of HE, compared with SOC.	Only individual data of those patients fulfilling the high-risk criteria (Child-Pugh B with active bleeding and Child-Pugh C < 14 points) from included studies were included. On multivariate analysis patients with Child-Pugh score > 7 points had a significantly worse survival than those with Child-Pugh score ≤ 7. Both prospective and observational studies were included and latest UK RCT[46] and the multicentre French audit[50] were not included.
Tripathi et al[54]	3 RCTs[39,44,46] comparing e-TIPSS (with covered stent) with SOC, comprising 152 patients.	e-TIPSS significantly reduced incidence of re-bleeding (RR = 0.20; P ≤ 0.001). Improvement in overall survival at 1 and 2 yr was not statistically significant between two groups (RR = 0.62; P = 0.16 and RR = 0.62; P = 0.19 respectively).	There was no significant difference in incidence of HE. RCTs are underpowered to reach firm conclusion about the survival benefit of e-TIPSS.

e-TIPSS: Early transjugular intrahepatic portosystemic stent-shunt; RCT: Randomised controlled trial; SOC: Standard of care; HE: Hepatic encephalopathy.