title: Early-TIPSS placement prevents rebleeding in high-risk patients with variceal bleeding, without improving survival.
abstract: BACKGROUND
  Early-TIPSS (transjugular intrahepatic portosystemic shunt) placement may improve rebleeding and reduce 1-year mortality, compared to standard management in high-risk patients with cirrhosis and variceal bleeding.
  
  
  OBJECTIVE
  To obtain external validation of this therapeutic approach.
  
  
  METHODS
  We performed a prospective study including all consecutive patients with Child-Pugh C 10-13 cirrhosis or Child-Pugh B with active bleeding at endoscopy admitted to our ICU between March 2011 and February 2013 for variceal bleeding. TIPSS were placed within 72 h after stabilisation. Patients were matched for gender, age, Child-Pugh score, MELD score and to patients from a historical cohort hospitalised before March 2011.
  
  
  RESULTS
  31/128 patients with cirrhosis (77.4% men, mean age 53.2 ± 9.0 years old, MELD score 20.9 ± 6.9, Child-Pugh C: 77.4%) admitted for acute variceal bleeding between March 2011 and February 2013 (TIPSS+ group) were matched to 31 historical patients (TIPSS- group). Uncontrolled bleeding occurred in 1/31 patients in the TIPSS+ group vs. 2/31 patients in TIPSS- group (P = 0.55). The 1-year probability of being free of rebleeding was higher in the TIPSS+ group (97% vs. 51%, P < 0.001). Actuarial 1-year survival was not different between the two groups (66.8 ± 9.4% vs. 74.2 ± 7.8%, P = 0.78). Acute cardiac failure occurred more frequently in the TIPSS+ group (25.8% vs. 6.4%, P = 0.03).
  
  
  CONCLUSIONS
  Early-TIPSS placement effectively prevents rebleeding in high-risk patients with variceal bleeding but does not significantly improve survival. This might be due to the high proportion of patients with Child-Pugh C cirrhosis in our series. Cardiac failure may play a role and must be investigated before the procedure, when possible.
authors.affiliation: Department of Hepatogastroenterology, La Pitié-Salpêtrière Hospital, 47-80 boulevard de l'Hôpital, Assistance Publique-Hôpitaux de Paris, Pierre et Marie Curie University, Paris, France.
authors.forename: M
authors.initials: M
authors.lastname: Rudler
authors.forename: P
authors.initials: P
authors.lastname: Cluzel
authors.forename: T L
authors.initials: TL
authors.lastname: Corvec
authors.forename: H
authors.initials: H
authors.lastname: Benosman
authors.forename: G
authors.initials: G
authors.lastname: Rousseau
authors.forename: T
authors.initials: T
authors.lastname: Poynard
authors.forename: D
authors.initials: D
authors.lastname: Thabut
mesh_terms: D000368:Aged; D015331:Cohort Studies; D005260:Female; D005500:Follow-Up Studies; D006471:Gastrointestinal Hemorrhage / Q000209:etiology / Q000401:mortality / Q000517:prevention & control; D006470:Hemorrhage / Q000209:etiology / Q000401:mortality* / Q000517:prevention & control*; D006801:Humans; D008103:Liver Cirrhosis / Q000150:complications / Q000401:mortality* / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D019168:Portasystemic Shunt, Transjugular Intrahepatic / Q000009:adverse effects / Q000379:methods* / Q000401:mortality*; D011446:Prospective Studies; D012307:Risk Factors; D015996:Survival Rate / Q000639:trends; D013997:Time Factors