Rebleeding rates following TIPS for variceal hemorrhage in the Viatorr era: TIPS alone versus TIPS with variceal embolization

Abstract

Purpose: To compare rebleeding rates following treatment of variceal hemorrhage with TIPS alone versus TIPS with variceal embolization in the covered stent-graft era.

Methods: In this retrospective study, 52 patients (M:F 29:23, median age 52 years) with hepatic cirrhosis and variceal hemorrhage underwent TIPS insertion between 2003 and 2008. Median Child-Pugh and MELD scores were 8.5 and 13.5. Generally, 10-mm diameter TIPS were created using covered stent-grafts (Viatorr; W.L. Gore and Associates, Flagstaff, AZ). A total of 37 patients underwent TIPS alone, while 15 patients underwent TIPS with variceal embolization. The rates of rebleeding and survival were compared.

Results: All TIPS were technically successful. Median portosystemic pressure gradient reductions were 13 versus 11 mmHg in the embolization and non-embolization groups. There were no statistically significant differences in Child-Pugh and MELD score, or portosystemic pressure gradients between each group. A trend toward increased rebleeding was present in the non-embolization group, where 8/37 (21.6%) patients rebled while 1/15 (6.7%) patients in the TIPS with embolization group rebled (P = 0.159) during median follow-up periods of 199 and 252 days (P = 0.374). Rebleeding approached statistical significance among patients with acute hemorrhage, where 8/32 (25%) versus 0/14 (0%) rebled in the non-embolization and embolization groups (P = 0.055). A trend toward increased bleeding-related mortality was seen in the non-embolization group (P = 0.120).

Conclusions: TIPS alone showed a high incidence of rebleeding in this series, whereas TIPS with variceal embolization resulted in reduced recurrent hemorrhage. The efficacy of embolization during TIPS performed for variceal hemorrhage versus TIPS alone should be further compared with larger prospective randomized trials.

Keywords: Embolization; Rebleeding; Transjugular intrahepatic portosystemic shunt (TIPS); Variceal hemorrhage.

Fig. 1

Graphs of Kaplan–Meier estimation of a rebleeding probability among all patients undergoing TIPS with variceal coil embolization versus TIPS without embolization (P = 0.159). b Rebleeding probability among patients with acute hemorrhage undergoing TIPS with variceal coil embolization versus TIPS without embolization (P = 0.055)

Fig. 2

A 52-year-old man with alcoholic cirrhosis and bleeding gastric varices. Portal venogram (a) performed during TIPS insertion demonstrates prominent gastrosplenic (arrowhead) and coronary (arrow) varices. Note right portal vein thrombosis. Post-TIPS portal venogram (b) performed following gastrosplenic variceal embolization shows minimal residual coronary vein opacification (arrow). This vessel was not embolized given significant portosystemic gradient reduction from 25 to 6 mmHg. Patient rebled 538 days post-TIPS due to shunt occlusion, evidenced on venous phase imaging following superior mesenteric arteriogram (c). Note coronary vein and gastric variceal filling (arrows), as well as right portal vein recanalization

Fig. 3

Graphs of Kaplan–Meier estimation of a overall survival probability among patients undergoing TIPS with variceal coil embolization versus TIPS without embolization (P = 0.746). b Bleeding related mortality among patients undergoing TIPS with variceal coil embolization versus TIPS without embolization (P = 0.120)