Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria; Div. of Gastroenterology & Hepatology, Dept. of Internal Medicine III, Medical University of Vienna, Vienna, Austria.
Dept. of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria.
Dig Liver Dis. 2017 Dec;49(12):1360-1367. doi: 10.1016/j.dld.2017.08.002. Epub 2017 Aug 8.
Early implantation (<72h) of a transjugular intrahepatic portosystemic shunt (TIPS) after acute variceal bleeding (AVB) improves survival in highly selected patients.
We retrospectively assessed bleeding control and survival of unselected cirrhotic patients undergoing early TIPS implantation within 72h. We compared the outcomes to patients meeting early TIPS criteria but receiving late TIPS within 3-28days after AVB and endoscopic/medical treatment.
Forty-nine patients were included. Mean MELD was 14.4 (±4.4). Thirteen patients (26.5%) presented characteristics that were exclusion criteria in previous early TIPS trials (age>75, CPS>13, HCC>Milan, previous beta-blocker/band-ligation, renal insufficiency). Bare metal and PTFE-covered stents were used in n=32 (65.3%) and n=17 (34.7%) patients, respectively, and showed similar early re-bleeding rates (9.9% vs. 7.1%; p=0.6905) and bleeding-related mortality (25.0% vs. 23.5%; p=0.9906). However, overall re-bleeding rate was lower with PTFE-TIPS (7.7% vs. 64.2%; p=0.0044) over a median follow-up of 18.5 months with a tendency towards improved survival (median 70.5 vs. 13.8 months; p=0.204). Additional 68 patients meeting stringent criteria but receiving late TIPS also showed a favorable bleeding-related mortality (8.8%), which was not achieved in similar n=34 patients by a medical/endoscopic strategy with bleeding-related mortality of 35.7%.
An early TIPS strategy using covered stents and implementation of 'stringent criteria' results in a favorable outcome in patients with acute variceal bleeding.
在急性静脉曲张出血 (AVB) 后 72 小时内早期植入经颈静脉肝内门体分流术 (TIPS) 可改善高度选择的患者的生存率。
我们回顾性评估了在 72 小时内接受早期 TIPS 植入的未经选择的肝硬化患者的出血控制和生存率。我们将结果与符合早期 TIPS 标准但在 AVB 和内镜/药物治疗后 3-28 天内接受晚期 TIPS 的患者进行了比较。
共纳入 49 例患者。平均 MELD 为 14.4(±4.4)。13 例患者(26.5%)具有既往早期 TIPS 试验的排除标准特征(年龄>75 岁、CPS>13、HCC>Milan、既往β受体阻滞剂/套扎、肾功能不全)。32 例患者(65.3%)和 17 例患者(34.7%)分别使用裸金属支架和 PTFE 覆膜支架，早期再出血率相似(9.9% vs. 7.1%；p=0.6905)，出血相关死亡率相似(25.0% vs. 23.5%；p=0.9906)。然而，在中位随访 18.5 个月时，PTFE-TIPS 的总体再出血率较低(7.7% vs. 64.2%；p=0.0044)，且生存趋势改善(中位 70.5 个月 vs. 13.8 个月；p=0.204)。另外 68 例符合严格标准但接受晚期 TIPS 的患者出血相关死亡率也较低(8.8%)，而采用类似的 n=34 例患者内镜/药物治疗策略，出血相关死亡率为 35.7%。
在急性静脉曲张出血患者中，采用覆膜支架的早期 TIPS 策略并实施“严格标准”可获得良好的结局。
