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

Abstract

Variceal bleeding is a serious complication of cirrhosis and portal hypertension. Despite the improvement in management of acute variceal bleed (AVB), it still carries significant mortality. Portal pressure is the main driver of variceal bleeding and also a main predictor of decompensation. Reduction in portal pressure has been the mainstay of management of variceal bleeding. Transjugular intrahepatic porto-systemic stent shunt (TIPSS) is a very effective modality in reducing the portal hypertension and thereby, controlling portal hypertensive bleeding. However, its use in refractory bleeding (rescue/salvage TIPSS) is still associated with high mortality. “Early” use of TIPSS as a “pre-emptive strategy” in patients with AVB at high risk of failure of treatment has shown to be superior to standard treatment in several studies. While patients with Child C cirrhosis (up to 13 points) clearly benefit from early-TIPSS strategy, it’s role in less severe liver disease (Child B) and more severe disease (Child C > 13 points) remains less clear. Moreover, standard of care has improved in the last decade leading to improved 1-year survival in high-risk patients with AVB as compared to earlier “early” TIPSS studies. Lastly in the real world, only a minority of patients with AVB fulfil the stringent criteria for early TIPSS. Therefore, there is unmet need to explore role of early TIPSS in management of AVB in well-designed prospective studies. In this review, we have appraised the role of early TIPSS, patient selection and discussed future directions in the management of patients with AVB.

Keywords: Transjugular intrahepatic portosystemic stent-shunt, Early transjugular intrahepatic portosystemic stent-shunt, Salvage transjugular intrahepatic portosystemic stent-shunt, Portal hypertension, Acute variceal bleed, Hepatic encephalopathy

Core Tip: Outcome of high-risk patients following episode of acute variceal bleeding (AVB) is poor and insertion of transjugular intrahepatic portosystemic stent-shunt (TIPSS) within 72 h of index endoscopy (early or pre-emptive TIPSS) is associated with remarkable outcomes in a selection of patients (Child C up to 13 points). However, it’s efficacy in Child B patients is debatable and criteria for high-risk patients needs to be refined. Moreover, management of variceal bleeding has improved in last decade and provision of early TIPSS (within 72 h) is challenging in most healthcare facilities. In this paper we have discussed the role of early TIPSS, patient selection and future directions in management of AVB.