Preemptive TIPS Promising for Fundal Variceal Bleeding

TOPLINE:

In patients with cirrhosis and acute fundal variceal bleeding, the use of preemptive transjugular intrahepatic portosystemic shunt (p-TIPS) with a covered stent within 72 hours of initial bleeding resulted in superior outcomes, with a higher probability of patients being free of death or rebleeding at 1 year than those using standard treatment.

METHODOLOGY:

• Researchers conducted a randomised trial across 17 tertiary centres in France to compare two strategies for preventing rebleeding of non-type 1 gastro-oesophageal varices.
• They included 101 patients with cirrhosis and acute fundal variceal bleeding (mean age, 58.2 years; 80% men) from January 3, 2019, to February 25, 2023, who achieved initial haemostasis with endoscopic glue injection for at least 12 hours.
• Patients were randomly assigned to either receive p-TIPS within 72 hours of the initial endoscopic glue injection (n = 47) or continue with on-demand glue obliteration combined with non-selective beta blockers (n = 54).
• The primary composite endpoint was all-cause mortality or clinically significant rebleeding, defined as recurrent melena or haematemesis requiring hospitalisation or blood transfusion or causing a 3 g/dL drop in haemoglobin, within 1 year from the initial haemostasis. Analyses were conducted in the modified intention-to-treat population.

TAKEAWAY:

• The 1-year probability of being free from death or rebleeding was higher in the p-TIPS group than in the glue obliteration and non-selective beta-blocker group (77% vs 37%; hazard ratio, 0.25; P < .0001).
• The overall survival did not differ significantly between the two groups; however, 37% of patients in the glue obliteration and non-selective beta-blocker group required TIPS after a median of 25 days. The cumulative incidence of hepatic encephalopathy at 1 year was 35% in the p-TIPS group and 32% in the glue obliteration and non-selective beta-blocker group.
• Complications related to glue injection occurred in 22 procedures, including 13 bleeding episodes, eight glue migrations (three in the p-TIPS group and five in the glue obliteration group), and one case of cardiac decompensation in the p-TIPS group.
• The number of patients who experienced any adverse or serious adverse event did not differ significantly between the groups, and no deaths were considered related to the treatment.

IN PRACTICE:

“The results of the present study strongly support the use of p-TIPS in the management of acute gastric variceal bleeding and add an additional argument in favour of TIPS, which improves prognosis by effectively treating the haemodynamic disorders associated with cirrhosis,” the authors of the study wrote. “In patients with cirrhosis and bleeding from fundal varices, p-TIPS with a covered stent is associated with markedly decreased death or rebleeding and should therefore be considered as a first-line therapy,” they added.

SOURCE:

This study was led by Jean-Paul Cervoni, MD, Service d’Hépatologie et de Soins Intensifs, CHU Besançon, Besançon, France. It was published online on June 12, 2025, in The Lancet Gastroenterology & Hepatology.

LIMITATIONS:

A small sample size precluded definitive subgroup analyses (eg, variceal type). An overrepresentation of alcohol-related cirrhosis may have limited the applicability of the findings to other aetiologies. Eight patients in the p-TIPS group were treated beyond the 72-hour window.

DISCLOSURES:

This study was funded by the French Ministry of Health. Two authors reported receiving payment for lectures and one author reported receiving consulting fees from Gore.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.