A case-control study of transjugular intrahepatic portosystemic stent shunts for patients admitted to intensive care following variceal bleeding.
BACKGROUND
Variceal bleeding has a 6-week mortality of 20%. Recent evidence suggests that early covered transjugular intrahepatic portosystemic stent shunts (TIPSS) can improve outcomes following a variceal bleed in selected patients. We aim to assess the outcomes following the insertion of covered TIPSS in a real-life intensive care setting.


METHODS
This is a retrospective matched cohort study of all patients referred for TIPSS with variceal bleeding admitted to intensive care (2007-2009). Patients were matched with others admitted to intensive therapy unit following a variceal bleed but did not proceed to TIPSS. All TIPSS procedures were carried out using polytetrafluoroethylene-covered stents.


RESULTS
Thirty-eight patients [mean age 55.2 years; mean model for end-stage liver disease (MELD)=14.0; and median follow-up 458 days] were assessed. Nineteen underwent TIPSS and were well matched to the controls. All patients received terlipressin and antibiotics and 86% had active bleeding at endoscopy. Indication for TIPSS was salvage therapy (47%), rebleeding after day 5 (11%) and as secondary prophylaxis (42%). There was 34% all-cause inpatient mortality. The TIPSS group had lower mortality than the non-TIPSS group at 6 weeks (10.5 vs. 47.4%, P<0.05) that persisted at 1 year (21.1 vs. 52.6%, P<0.05). Multivariate analysis indicated MELD [HR 1.131, 95% confidence interval (CI) 1.018-1.257] and TIPSS (HR 0.301, 95% CI 0.091-0.995) as significant predictors of mortality (P<0.05). TIPSS was found to significantly reduce the incidence of failure to control bleeding and rebleeding (HR 0.120, 95% CI 0.015-0.978, P<0.05).


CONCLUSIONS
Patients with recent severe variceal bleeding admitted to intensive care have significantly better outcomes following covered TIPSS insertion. These findings should be validated in randomized-controlled trials.
Liver Unit, Queen Elizabeth Hospital, Birmingham, Birmingham, UK. chris.corbett@nhs.net
Chris
C
Corbett
Nick
N
Murphy
Simon
S
Olliff
Kamarjit S
KS
Mangat
Dhiraj
D
Tripathi
D000368:Aged; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D016009:Chi-Square Distribution; D004932:Esophageal and Gastric Varices / Q000150:complications / Q000401:mortality / Q000601:surgery*; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000209:etiology / Q000401:mortality / Q000601:surgery*; D017052:Hospital Mortality; D006801:Humans; D007362:Intensive Care Units; D053208:Kaplan-Meier Estimate; D008236:Lypressin / Q000031:analogs & derivatives / Q000627:therapeutic use; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D010343:Patient Admission; D011138:Polytetrafluoroethylene; D019168:Portasystemic Shunt, Transjugular Intrahepatic / Q000009:adverse effects / Q000295:instrumentation / Q000401:mortality; D016016:Proportional Hazards Models; D011474:Prosthesis Design; D012189:Retrospective Studies; D012307:Risk Factors; D015607:Stents; D000077585:Terlipressin; D013997:Time Factors; D016896:Treatment Outcome; D014662:Vasoconstrictor Agents / Q000627:therapeutic use
D000900:Anti-Bacterial Agents; D014662:Vasoconstrictor Agents; D008236:Lypressin; D000077585:Terlipressin; D011138:Polytetrafluoroethylene