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. 2025 Apr 2;87(5):2936-2947.
doi: 10.1097/MS9.0000000000003215. eCollection 2025 May.

Efficacy and safety of transjugular intrahepatic portosystemic shunt versus endoscopic variceal ligation for variceal rebleeding: a systematic review and meta-analysis

Abdelaziz A Awad  1 , Alaa Ramadan  2 , Abdelrahman M Elettreby  3 , Yousef Radwan Alnomani  4 , Ahmed Hamdy Zabady  5 , Esraa Abdelhafz  6 , Yousef Ahmed Elamin  7 , Mahmoud Ali  8 , Merna R Roshdy  9 , Omar Abdelrahim  10 , Moustafa S Mohamed  11 , Mohamed Elmasry  12 , Naji Al-Bawah  13 , Mohamed Fakhry  14
Affiliations

Efficacy and safety of transjugular intrahepatic portosystemic shunt versus endoscopic variceal ligation for variceal rebleeding: a systematic review and meta-analysis

Abdelaziz A Awad et al. Ann Med Surg (Lond). .

Abstract

Background: Variceal bleeding is a significant cause of morbidity and mortality among patients with cirrhosis. While both transjugular intrahepatic portosystemic shunt (TIPS) and endoscopic variceal ligation (EVL) are utilized for variceal rebleeding prevention, their comparative efficacy and safety remain debated.

Methods: A systematic review and meta-analysis were conducted to compare TIPS with EVL for variceal rebleeding prevention. A comprehensive search of electronic databases on PubMed, Embase, Scopus, and Web of Science identified 16 studies meeting inclusion criteria. Data on outcomes including gastrointestinal bleeding, variceal rebleeding, hepatic encephalopathy, treatment failure, and mortality were extracted and analyzed.

Results: TIPS was associated with significantly lower rates of gastrointestinal bleeding (RR = -0.69, 95% CI [-0.92, -0.47], P < 0.001), variceal rebleeding (RR: -0.99, 95% CI [-1.2, -0.79], P < 0.001), and bleeding from banding ulcers (RR: -1.51, 95% CI [-2.75, -0.27], P = 0.02) compared to EVL. However, TIPS was linked to higher rates of hepatic encephalopathy (RR: 0.44, 95% CI [0.18, 0.71], P < 0.001) and treatment failure (RR: -1.29, 95% CI [-2.01, -0.57], P < 0.001). No significant differences were found in mortality, liver failure, hepatocellular carcinoma, or other clinical outcomes between the two interventions.

Conclusion: TIPS demonstrates superiority over EVL in reducing variceal rebleeding and gastrointestinal bleeding. However, it is associated with higher rates of hepatic encephalopathy and treatment failure. Individualized treatment decisions should consider patient characteristics and treatment goals to optimize outcomes in variceal bleeding management. Further research is warranted to refine treatment strategies and minimize adverse events associated with both interventions.

Keywords: EVL; TIPS; cirrhosis; endoscopic variceal ligation; meta-analysis; transjugular intrahepatic portosystemic shunt; variceal bleeding.

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Conflict of interest statement

Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article. The authors declare no conflicts of interest related to this work.

Figures

Figure 1.
Figure 1.
PRISMA flow diagram of the selection process.
Figure 2.
Figure 2.
Risk of bias and summary of the included studies.
Figure 3.
Figure 3.
Forest Plot of the GI bleeding.
Figure 4.
Figure 4.
Forest Plot of the variceal rebleeding.
Figure 5.
Figure 5.
Trial sequential analysis of the hepatic encephalopathy.
See this image and copyright information in PMC

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