TIPS for Variceal Bleeding A Clinical Update · • Variceal bleeding occurs in 25-35% of cirrhotics and accounts for 70-80% of UGIB in these patients • The 1-year rate of recurrent
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TIPS for Variceal Bleeding A Clinical Update
Prof. Romaric Loffroy
Department of Vascular and Interventional Radiology
François-Mitterrand Teaching Hospital
Dijon, France
Disclosure
Speaker name: Prof. Romaric Loffroy
.................................................................................
I have the following potential conflicts of interest to report:
Consulting (Gore, GEM, Medtronic, Guerbet)
Employment in industry
Stockholder of a healthcare company
Owner of a healthcare company
Other(s)
I do not have any potential conflict of interest
• One of the major complications of portal hypertension from cirrhosis
• Variceal bleeding occurs in 25-35% of cirrhotics and accounts for
70-80% of UGIB in these patients
• The 1-year rate of recurrent variceal bleeding is approximately 60%
• The 6-week mortality with each episode of variceal bleeding is
approximately 10-20%
– From 0% among patients with Child class A disease to 30% among
patients with Child class C disease
Gastroesophageal Variceal Bleeding
De Franchis R. J Hepatol 2010
Prevalence Of Esophageal Varices In
Patients With Newly-Diagnosed Cirrhosis
%
Patients
with
varices
100
60
40
20
0
Overall Child A Child B
80
Child C
Pagliaro et al., In: Portal Hypertension: Pathophysiology and Management, 1994
Predictors of bleeding:
Variceal size
Red signs
Child B and Child C
Variceal bleeding Varix with red signs
NIEC. N Engl J Med 1988;319:983
Re
du
ctio
n in
po
rta
l p
ressure
(%
) ß-blocker
ß-blocker + nitratesnitrates
vasopressin
vasopressin + nitrates
terlipressin
terlipressin + nitrates
somatostatin,octreotide
TIPS50
40
30
20
10
0
Reduction Of Portal Pressure
Pagliaro et al., In: Portal Hypertension: Pathophysiology and Management, 1994
(CSPH = HVPG ≥ 10 mm Hg)
Less dysfunction Less
encephalopathy
Better survival
Yang et al. J Gastroenterol Hepatol 2010
• PRIMARY PROPHYLAXIS:
Systematic screening of all cirrhotic patients with OG endoscopy:
- Except if liver stiffness <20kPa and platelet count >150,000
In case of OV grade 1:
- If patient Child C or red signs and in the absence of CI: NSBB
- In all other cases: surveillance (benefit of NSBB discussed)
In case of OV grade 2 to 3:
- Treatment with NSBB or EBL according to underlying conditions
- No therapeutic association at this stage
- Carvedilol (Kredex®): interesting alternative
In case of gastric varices: treatment with NSBB
De Franchis R. J Hepatol 2015
• SECONDARY PROPHYLAXIS:
In case of ruptured OV: first-line therapy = NSBB + EVL
→ If CI or intolerance to NSBB: EVL
→ If refusal of EVL: NSBB
If recurrence despite well-conducted prophylaxis: covered TIPS
+/- Associated with pretransplantation work-up
In case of bleeding from tuberocardiac varices:
→ If IGV 1 or GOV 2: iterative gluing or TIPS
→ If GOV 1: NSBB with EVL or gluing
In case of bleeding from gastropathy: NSBB
De Franchis R. J Hepatol 2015
Meta-analysis: TIPS vs Endoscopic Therapy
TIPS As First-Line Therapy After Variceal
Bleeding?
Portal pressure is >20mm Hg. These are high
risk patients: TIPS effectively reduces portal
pressure
Child A and B, MELD 10. Discuss early tips
candidates due to high portal pressures
70% Alcohol cirrhotic. Presenting with 50%
varices, 50% ascites
• A significantly smaller proportion of patients in the TIPS group had rebleeding
within 2 years (7%) than in the medical group (26%) (P=.002)
• A slightly higher proportion of patients in the TIPS group experienced adverse
events, including encephalopathy (18% vs 8% for medical treatment; P=.05)
Sauerbruch et al. Gastroenterology 2015
Authors’ conclusions
• 8-mm cTIPS as first line elective rebleeding prevention is simple and more effective than drugs in moderately decompensated cirrhosis
• However, TIPS did not increase survival time or quality of life and produced slightly more adverse events
• Information are needed on drug response early on
• TIPS loses superiority in the prevention of rebleeding if placed >3 weeks after the index bleeding
Sauerbruch et al. Gastroenterology 2015
• ACUTE VARICEAL BLEEDING:
Association of medical and endoscopic treatments remains the
first-line therapy for all patients
Immediate measures:
- Hospitalization in ICU, transfusion (target 8g/dl)
- Antibiotics (C3G)
- Vaso-active drugs for 5 days
- OGD within 12h for EBL or glue injection
- Blakemore tube in case of massive bleeding, before TIPS
De Franchis R. J Hepatol 2015
TIPS must be considered:
- Either in mid-emergency: salvage TIPS if massive bleeding
- Or novelty: early TIPS (<72h, ideally <24h) to consider in patients at high risk
of treatment failure (Child C <14 or Child B with active bleeding)
Variceal Bleeding
Vasoactive drugs + endoscopic treatment + AB
Success
80-90%
Refractory or recurrent bleeding
10-20%
Death Alive
Blakemore, TIPS
Child-Pugh C, (MELD score) HVPG > 20 mmHg Active bleeding at endoscopy
Author Nb patients Child A/B/C Bleeding control Mortality
Mc Cormick 20 1/7/12 100% 55%
Jalan 19 3/3/13 100% 42%
Sanyal 30 1/7/22 100% 40%
Chau 112 5/27/80 98% 37%
Gerbes 11 1/3/7 100% 27%
Banares 56 11/22/23 96% 28%
Azoulay 58 3/8/47 93% 30%
Bilbao et al. CVIR 2002
Salvage TIPS
Early TIPS vs Medical Treatment In Patients With Acute Variceal Hemorrhage And HVPG > 20 mmHg (High Risk) May Improve Survival
0
0.2
0.4
0.6
0.8
1
0 12 9 6 3
HVPG <20
HVPG >20 - TIPS
HVPG >20 – No TIPS
Probability
of survival
Months
Monescillo et al. Hepatology 2004;40:793
Garcia-Pagan et al. N Engl J Med 2010
Garcia-Pagan et al. N Engl J Med 2010
Previous literature on early TIPS:
- Efficient on rebleeding
- Increases hepatic encephalopathy
- No survival impact
Study from Garcia-Pagan:
- Different population: only high-risk patients
- Use of covered stents
- Decision not based on HVPG measurement
Garcia-Pagan et al. N Engl J Med 2010
TIPS For Secondary Prophylaxis Or Early TIPS: Economic Point Of View
Any Role For Variceal Embolization ?
From Loffroy R et al. World J Gastroenterol 2013
• ACUTE BLEEDING: - Salvage TIPS: if serious refractory bleeding after Blakemore tube
- Early TIPS < 24h: if Child C < 14 or Child B with active bleeding
• SECONDARY PROPHYLAXIS: - In case of failure of usual prophylaxis
- In case of initial bleeding from IGV1 or GOV2
• ON THE WAY: - Use of early TIPS in gastric varices?
- Role of covered TIPS as first line therapy after variceal bleeding: secondary prophylaxis?
Conclusion: When Gore Viatorr® TIPS Must Be Considered?
Baveno VI Statement. J Hepatol 2015
TIPS for Variceal Bleeding A Clinical Update
Prof. Romaric Loffroy
Department of Vascular and Interventional Radiology
François-Mitterrand Teaching Hospital
Dijon, France
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