8 小时内行紧急抢救性经颈静脉肝内门体分流术可提高难治性静脉曲张出血患者的生存率。
Emergent rescue transjugular intrahepatic portosystemic shunt within 8 h improves survival in patients with refractory variceal bleed.
机构信息
Department of Intervention Radiology, Institute of Liver and Biliary Sciences, New Delhi, India.
Department of Hepatology, Institute of Liver and Biliary Sciences, D - 1, Vasant Kunj, New Delhi, 110070, India.
出版信息
Hepatol Int. 2023 Aug;17(4):954-966. doi: 10.1007/s12072-022-10479-5. Epub 2023 Feb 14.
BACKGROUND
Transjugular-intrahepatic portosystemic-shunt (TIPS) and SX-Ella stent Danis (DE stent) are available rescue therapies for refractory variceal bleeding in cirrhosis. Any delay in appropriate therapy is associated with high mortality. Determining the best timing for rescue TIPS is crucial and largely unknown.
METHODS
Cirrhotic patients with refractory variceal bleed (n = 121) who underwent rescue TIPS within 24-h (n = 66) were included. Their early rebleed (upto 42 days) rate, 6-week and 1-year survival were compared with matched patients who underwent rescue DE stent (n = 55). Outcomes based on timing of TIPS (within 8-h/8-24 h) were also analyzed.
RESULTS
At baseline, patients who received rescue DE stent were sicker with higher MELD score (27.6 ± 8.3 vs. 22.3 ± 7.9; p = 0.001), active bleeding at endoscopy (54.5% vs. 34.8%; p = 0.03) compared to TIPS-group. After propensity score matching, adjusting for MELD-Na score and non-bleed complications, DE patients (n = 34) had higher mortality at 6-week (17/34; 50%) and 1-year (29/34; 85.3%) compared to TIPS-group (20.6% and 38.2%, respectively; both p < 0.02), with higher rebleeding rate (10/34; 29.4% vs. 1/34; 2.9%, p = 0.003). Rescue TIPS placed within 8-h compared with 8-24 h had lower 6-week (48.6% vs. 12.9%; p = 0.003) and 1-year mortality (62.9% vs. 16.1%, p = 0.001) despite comparable rebleed rates (2/31; 6.5% vs. 2/35;5.7%; p = 0.90). Post-TIPS Portal pressure gradient at 6-weeks and 1-year was comparable between survivors and non-survivors. Active bleeding at endoscopy [HR = 11.8; 95% CI 2.96-47.53], presence of AKI [HR = 5.8; 95% CI 1.92-17.41], MELD-Na > 24 [HR = 1.1; 95% CI 1.0-1.17], mean arterial pressure > 64.5 mmHg [HR = 0.8; 95% CI 0.75-0.92] independently predicted 6-week mortality in rescue TIPS-group.
CONCLUSIONS
Rescue TIPS placement preferably within 8-h of refractory variceal bleed improves short- and long-term survival. It provides better outcome than DE stent for control of bleeding and prevention of rebleeding, even in patients with high MELD-Na score.
背景
经颈静脉肝内门体分流术（TIPS）和 SX-Ella 支架（DE 支架）是肝硬化难治性静脉曲张出血的可选择的挽救性治疗方法。任何适当治疗的延误都与高死亡率相关。确定挽救性 TIPS 的最佳时机至关重要，但目前仍知之甚少。
方法
纳入了在 24 小时内（n=66）接受挽救性 TIPS 的难治性静脉曲张出血（n=121）的肝硬化患者。与接受挽救性 DE 支架治疗的匹配患者（n=55）相比，比较了他们的早期再出血（最多 42 天）率、6 周和 1 年生存率。还根据 TIPS 时机（8 小时内/8-24 小时）进行了分析。
结果
在基线时，接受挽救性 DE 支架治疗的患者病情更严重，MELD 评分更高（27.6±8.3 vs. 22.3±7.9；p=0.001），内镜下有活动性出血（54.5% vs. 34.8%；p=0.03）。在进行倾向评分匹配后，调整 MELD-Na 评分和非出血并发症后，与 TIPS 组相比，DE 组（n=34）在 6 周（17/34；50%）和 1 年（29/34；85.3%）的死亡率更高（均 p<0.02），再出血率更高（10/34；29.4% vs. 1/34；2.9%；p=0.003）。与 8-24 小时相比，TIPS 在 8 小时内放置，尽管再出血率相似（2/31；6.5% vs. 2/35；5.7%；p=0.90），但 6 周（48.6% vs. 12.9%；p=0.003）和 1 年（62.9% vs. 16.1%；p=0.001）的死亡率更低。在幸存者和非幸存者之间，6 周和 1 年的 TIPS 后门静脉压力梯度是可比的。内镜下有活动性出血[HR=11.8；95%CI 2.96-47.53]、存在 AKI[HR=5.8；95%CI 1.92-17.41]、MELD-Na>24[HR=1.1；95%CI 1.0-1.17]、平均动脉压>64.5mmHg[HR=0.8；95%CI 0.75-0.92]均独立预测了 TIPS 组的 6 周死亡率。
结论
在难治性静脉曲张出血后的 8 小时内进行挽救性 TIPS 可改善短期和长期生存率。与 DE 支架相比，它在控制出血和预防再出血方面提供了更好的效果，即使在 MELD-Na 评分较高的患者中也是如此。
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