Celaj Stela, Estevez J, Novelli Paula, Orons Philip, Al-Khafaji Ali, Jonassaint Naudia L, Cruz Ruy J, Malik Shahid M
Division of Gastroenterology, Hepatology & Nutrition, University of Pittsburgh Medical Center, 200 Lothrop Street, Kaufmann Building, Suite 201, Pittsburgh, PA, 15213, USA.
Department of Interventional Radiology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
Dig Dis Sci. 2025 Jan;70(1):399-405. doi: 10.1007/s10620-024-08745-7. Epub 2024 Nov 25.
Since the overwhelmingly positive results of the 'early use of TIPS' published in 2010, studies in Europe and Asia have confirmed early/pre-emptive transjugular intrahepatic portosystemic shunt (p-TIPS) in high-risk patients with acute variceal bleed (AVB) reduces treatment failure and mortality compared to standard of care (SOC). There are no studies evaluating p-TIPS in a US cohort.
A review of patients with cirrhosis from June 2010 to June 2020 with AVB was conducted from a single large US center.
Of 745 cirrhotic patients with AVB, 18% met criteria for p-TIPS. Alcohol and HCV accounted for 75% of etiology; 13% MASLD. The mean MELD-Na score in our cohort was 24, which is ten points higher than reported in the literature for over 600 p-TIPS cases. Only 9 patients underwent p-TIPS. Patients undergoing p-TIPS were less likely to have MASLD, more likely to be female and less likely to have PSE at baseline. One-year mortality in the SOC group (including patients undergoing 'rescue TIPS') was 53% versus 0% for p-TIPS (p = 0.01).
Our observation suggests hesitancy among providers to recommend p-TIPS, likely due to concerns regarding a 'sicker' patient population. The current SOC in high-risk patients remain suboptimal. Limited data, including our own, suggest that p-TIPS may confer a survival benefit even in patients with high MELD. However, the recommendation of p-TIPS in such patients necessitates validation of its safety and efficacy. Consequently, we advocate for a RCT in the US to conclusively assess the utility of p-TIPS in this context. Until such evidence is established, it is likely that underutilization of this life-saving intervention will persist.
自2010年发表“早期使用经颈静脉肝内门体分流术（TIPS）”的压倒性积极结果以来，欧洲和亚洲的研究证实，与标准治疗（SOC）相比，对急性静脉曲张出血（AVB）高危患者进行早期/预防性经颈静脉肝内门体分流术（p-TIPS）可降低治疗失败率和死亡率。尚无在美国队列中评估p-TIPS的研究。
对美国一个大型单一中心2010年6月至2020年6月期间患有AVB的肝硬化患者进行回顾。
在745例患有AVB的肝硬化患者中，18%符合p-TIPS标准。酒精性和丙型肝炎病毒（HCV）病因占75%；非酒精性脂肪性肝病（MASLD）占13%。我们队列中的平均终末期肝病模型钠（MELD-Na）评分是24，比文献报道的600多例p-TIPS病例高10分。只有9例患者接受了p-TIPS。接受p-TIPS的患者患MASLD的可能性较小，女性可能性更大，基线时发生肝性胸水（PSE）的可能性较小。SOC组（包括接受“挽救性TIPS”的患者）的一年死亡率为53%，而p-TIPS组为0%（p = 0.01）。
我们的观察表明，医疗服务提供者对推荐p-TIPS存在犹豫，可能是由于对“病情更重”的患者群体存在担忧。高危患者目前的SOC仍然不理想。包括我们自己的数据在内的有限数据表明，即使是MELD评分高的患者，p-TIPS也可能带来生存益处。然而，在此类患者中推荐p-TIPS需要验证其安全性和有效性。因此，我们主张在美国进行一项随机对照试验（RCT），以最终评估p-TIPS在此情况下的效用。在确立此类证据之前，这种挽救生命的干预措施可能仍未得到充分利用。
