The role of the transjugular intrahepatic portosystemic stent shunt (TIPSS) in the management of bleeding gastric varices: clinical and haemodynamic correlations

TIPS versus endoscopic cyanoacrylate injection for the treatment of gastric fundal variceal rebleeding: a propensity score-matched retrospective cohort study

BACKGROUND

The optimal strategy for preventing rebleeding with gastroesophageal varices type 2 (GOV2) and isolated gastric varices type 1 (IGV1) is unclear. In this retrospective study, we aimed to compare the effectiveness and safety of transjugular intrahepatic portosystemic shunt (TIPS) and endoscopic cyanoacrylate injection (ECI) on GOV2 and IGV1 varices.

METHODS

In this retrospective cohort study, we collected data from patients with cirrhosis with GOV2 and IGV1 varices who received TIPS or ECI treatment between June 2018 and June 2023. The primary endpoint was rebleeding, and the secondary endpoints were death and overt hepatic encephalopathy (OHE). Propensity score matching (PSM) and adjusted survival curves were used to assess the robustness of the results.

RESULTS

A total of 111 eligible patients were included, of whom, 35 patients received TIPS and 76 patients received ECI. The median follow-up time for the TIPS and ECI groups were 746 and 683 days, respectively. TIPS reduced the all-cause rebleeding rate (14.3% versus 33.8%, p = 0.033; after PSM, 16.7% versus 40.0%, p = 0.045) compared with ECI, with lower risk of ectopic embolism (all were in the ECI group). The Incidence of OHE in the TIPS group was higher than that in the ECI group (28.6% versus 1.4%, p < 0.001; after PSM, 33.3% versus 3.3%, p < 0.001). However, no significant difference was found in mortality (17.1% versus 12.2%, p = 0.684; after PSM, 16.7% versus 16.7%, p = 1.000). The results were not affected by the adjusted survival curve.

CONCLUSION

TIPS was more effective than ECI in preventing rebleeding in patients with GOV2 and IGV1 varices with similar survival rates and lower risk of ectopic embolism, although TIPS was associated with a higher incidence of OHE.

Small Transjugular Intrahepatic Portosystemic Shunt Plus Variceal Embolization for Gastric Varices: A Multicenter Cohort Study

BACKGROUND & AIMS

The effect of transjugular intrahepatic portosystemic shunt (TIPS) plus variceal embolization for treating gastric varices (GVs) remains controversial. This nationwide multicenter cohort study aimed to evaluate whether adding variceal embolization to a small diameter (8-mm) TIPS could reduce the rebleeding incidence in patients with different types of GVs.

METHODS

This retrospective cohort study involved 629 patients who underwent 8-mm TIPS for gastric varices at 7 medical centers. The primary endpoint was all-cause rebleeding, and the secondary endpoints included overt hepatic encephalopathy (OHE) and all-cause mortality.

RESULTS

A total of 629 patients were included. Among them, 429 (68.2%) had gastroesophageal varices type 1 (GOV1), 145 (23.1%) had gastroesophageal varices type 2 (GOV2), and 55 (8.7%) had isolated gastric varices type 1 (IGV1). In the entire cohort, adjunctive embolization reduced rebleeding (6.2% vs 13.6%; P = .005) and OHE (31.0% vs 39.4%; P = .02) compared with TIPS alone. However, no significant differences were found in mortality (12.0% vs 9.7%; P = .42). In patients with GOV2 and IGV1, TIPS plus variceal embolization reduced both rebleeding (GOV2: 7.8% vs 25.1%; P = .01; IGV1: 5.6% vs 30.8%; P = .03) and OHE (GOV2: 31.8% vs 51.5%; P = .008; IGV1: 11.6% vs 38.5%; P = .04). However, in patients with GOV1, adjunctive embolization did not reduce rebleeding (5.9% vs 8.7%; P = .37) or OHE (33.1% vs 35.3%; P = .60).

CONCLUSIONS

Compared with TIPS alone, 8-mm TIPS plus variceal embolization reduced rebleeding and OHE in patients with GOV2 and IGV1. These findings suggest that patients with GOV2 and IGV1, rather than GOV1, could benefit from embolization with TIPS.

Trans-splenic anterograde coil-assisted transvenous occlusion (TACATO) of bleeding gastric varices associated with gastrorenal shunts in cirrhosis

Background & Aims

There is a lack of consensus on the optimal management of fundal gastric varices (GVs) in patients with cirrhosis due to varied anatomy and hemodynamics. In this study, we evaluate the safety and efficacy of trans-splenic anterograde coil-assisted transvenous occlusion (TACATO) for preventing recurrent bleeding in fundal GVs associated with gastrorenal shunt (GRS).

Methods

In this 4-year study, patients with cirrhosis with GRS-associated GV bleeding, without prior esophageal variceal bleeding, ascites, or portal vein thrombosis, were eligible for TACATO. Trans-splenic access was achieved by puncturing a splenic venous branch using ultrasound/fluoroscopic guidance. A microcatheter was inserted into the varices for embolization with detachable microcoils and possibly N-butyl-cyanoacrylate-Lipiodol. Technical success was assessed by venography. All patients underwent follow-up endoscopy and decompensating events were recorded. A retrospective external control group of patients with cirrhosis and similar GRS-associated GVs treated by retrograde transvenous obliteration was enrolled as a comparative group.

Results

Twenty patients with cirrhosis underwent TACATO (17 GOV2, 6 IGV1 - median GRS size 23 mm, range 15-32 mm). Median occlusion of the shunt was 90% (complete in 14/20); complications included local abdominal pain and partial splanchnic thrombosis in two patients. Over a median follow-up of 23 (range 10-31) months, no rebleeding or further decompensation occurred; liver function remained stable and endoscopy showed reduced or resolved fundal GVs without worsening esophageal varices in all patients. The comparative group (18 patients - median GRS diameter 14 mm, range 6-23 mm) reported no rebleeding but worsening varices in two and ascites progression in two.

Conclusions

TACATO is a viable option for secondary prophylaxis of bleeding from GVs associated with GRS and may reduce hepatic decompensation risk. Further studies are needed to validate these results and determine TACATO's broader role in GV management.

Impact and implications

Gastric varices (GVs) affect 20% of patients with cirrhosis, with a 2-year bleeding risk of 25%. Fundal GVs, which account for 70% of cases, are associated with mortality rates of up to 55%, posing management challenges due to their complex anatomy and hemodynamics. Transjugular intrahepatic portosystemic shunt placement often fails to address fundal GV hemodynamics, leaving patients at a high risk of rebleeding. Balloon-occluded retrograde transvenous obliteration, while effective, is limited by complexity, logistical hurdles, and complications. TACATO (trans-splenic anterograde coil-assisted transvenous occlusion) provides effective secondary prophylaxis for fundal GV bleeding linked to gastrorenal shunts. It matches the efficacy of retrograde and anterograde techniques while offering faster execution, minimal side effects, and no need for specialized equipment or gastrorenal shunt size restrictions. Trans-splenic access ensured safe and straightforward access to the portal system and fundal GVs in all patients treated with TACATO.

Three-dimensional volumetric CT image fusion and trans-abdominal US: Adjunct guidance to portal vein cannulation for TIPS

PURPOSE

To describe portal vein cannulation under adjunct guidance for transjugular intrahepatic portosystemic shunts (TIPS).

METHODS

Medical records of 86 patients who underwent TIPS, including conventional TIPS, 3D volumetric CT image fusion (CT-fluoroscopy image fusion)-guided TIPS, and trans-abdominal ultrasound (US)-guided TIPS at our institute from March 2016 to June 2024 were reviewed. Baseline characteristics, clinical outcomes, and procedural data were analyzed.

RESULTS

Technical success was achieved in 35 conventional TIPS patients (92.11 %), 20 CT-fluoroscopy image fusion-guided TIPS patients (95.24 %), and 26 transabdominal US-guided TIPS patients (96.30 %). Among patients who underwent a successful procedure, the procedural time and contrast usage were lower in the CT-fluoroscopy image fusion-guided and trans-abdominal US-guided TIPS groups than in the conventional group. There was a statistical significance in the cumulative fluoroscopic time between CT-fluoroscopy image fusion-guided TIPS and conventional TIPS groups (43.19 ± 14.92 vs 63.05 ± 30.33 min, p = 0.012). No immediate experienced complications were observed. Furthermore, the incidence of post-procedural complications among the three groups was not statistically different during follow-up.

CONCLUSIONS

CT-fluoroscopy image fusion and trans-abdominal US-guided portal vein cannulation are feasible, safe, and effective adjunct methods for patients undergoing TIPS. These methods provide shorter procedural time and lower contrast usage for TIPS placement.

Transjugular Intrahepatic Portosystemic Shunt (TIPS) for Treatment of Bleeding from Cardiofundal and Ectopic Varices in Cirrhosis

Acute variceal bleeding in cirrhosis represents a critical clinical event that significantly impacts patient prognosis, with mortality rates increasing further after a second episode. This underscores the need for immediate intervention and optimal prophylaxis. The creation of a transjugular intrahepatic portosystemic shunt (TIPS) has been proven to be highly effective for managing esophageal variceal bleeding. However, the use of TIPS for managing cardiofundal gastric varices and ectopic varices remains debated due to their unique vascular anatomy and the limited data available. These varices, although less prevalent than esophageal varices, are complex and heterogeneous vascular shunts between the splanchnic venous system and the systemic veins. Indeed, while endoscopic therapy with tissue adhesives is widely endorsed for achieving hemostasis in active hemorrhage, there is no consensus regarding the optimal approach for secondary prophylaxis. Recent research emphasizes the efficacy of endovascular techniques over endoscopic treatments, such as TIPS and endovascular variceal embolization techniques. This review examines the use of TIPS in managing acute variceal bleeding in patients with cirrhosis, focusing specifically on cardiofundal gastric varices and ectopic varices, discussing optimal patient care based on the latest evidence, aiming to improve outcomes for this challenging subset of patients.

Endoscopic ultrasound-guided treatment of isolated gastric varices entwined with arteries: A case report

BACKGROUND

Interventional endoscopic ultrasound is clinically used for the treatment of isolated gastric varices (IGVs) owing to its precise visualization.

CASE SUMMARY

A 39-year-old man was diagnosed with a large IGV during a routine physical examination. Endoscopic ultrasonography showed gastric varices entwined with an artery, which greatly increased the difficulty of treatment. We successfully treated the patient with endoscopic ultrasonography-guided coil embolization combined with cyanoacrylate injection.

CONCLUSION

Endoscopic ultrasonography-guided coil embolization combined with cyanoacrylate injection was safe and effective for the treatment of an IGV entwined with an artery.

Transjugular intrahepatic portosystemic shunt with or without variceal embolization to prevent variceal rebleeding: an updated meta-analysis

BACKGROUND

Transjugular intrahepatic portosystemic shunt (TIPS) is an established treatment for portal hypertension complications. Still, the role of adjuvant variceal embolization is a matter of debate. Thus, we aim to evaluate the efficacy and safety of TIPS with variceal embolization versus TIPS alone to prevent variceal rebleeding.

RESEARCH DESIGN AND METHODS

We used PubMed, CENTRAL, and OVID to search for all randomized controlled trials (RCTs) and comparative observational studies up to 17 June 20221117 June 2022. We pooled binary outcomes using risk ratios (RRs) presented with 95% confidence intervals (CIs) using RevMan 5.4.

RESULTS

We included 11 studies (two RCTs and nine observational studies) with 1024 patients. Pooled RR favored TIPS with embolization in preventing variceal rebleeding (RR 0.58, 95% CI: 0.44, 0.76); however, there was no difference between the two groups regarding shunt dysfunction (RR 0.92, 95% CI: 0.68, 1.23), encephalopathy (RR 0.88, 95% CI: 0.70, 1.11), and death (RR 0.97, 95% CI: 0.77, 1.22).

CONCLUSIONS

TIPS with embolization can be an effective strategy for preventing variceal rebleeding; however, our results should be interpreted cautiously as most data were observational and the technical quality of the embolization is questionable. Further RCTs are required using the proper techniques of embolization and comparing TIPS with embolization with other treatment modalities such as endoscopic ligation, and balloon-occluded retrograde transvenous obliteration.

Pathophysiology and management of liver cirrhosis: from portal hypertension to acute-on-chronic liver failure

Cirrhosis transcends various progressive stages from compensation to decompensation driven by the severity of portal hypertension. The downstream effect of increasing portal hypertension severity leads to various pathophysiological pathways, which result in the cardinal complications of cirrhosis, including ascites, variceal hemorrhage, and hepatic encephalopathy. Additionally, the severity of portal hypertension is the central driver for further advanced complications of hyperdynamic circulation, hepatorenal syndrome, and cirrhotic cardiomyopathy. The management of these individual complications has specific nuances which have undergone significant developments. In contrast to the classical natural history of cirrhosis and its complications which follows an insidious trajectory, acute-on-chronic failure (ACLF) leads to a rapidly downhill course with high short-term mortality unless intervened at the early stages. The management of ACLF involves specific interventions, which have quickly evolved in recent years. In this review, we focus on complications of portal hypertension and delve into an approach toward ACLF.

Endoscopic N-butyl-2-cyanoacrylate and ethanolamine oleate injection is equivalent to balloon-occluded retrograde transvenous obliteration for preventing gastric variceal bleeding

OBJECTIVES

Endoscopic injection sclerotherapy (EIS) is effective for temporary hemostasis, but EIS and balloon-occluded retrograde transvenous obliteration (BRTO) have been reported as effective for secondary prophylaxis of gastric varices (GV) bleeding. This study retrospectively compared EIS and BRTO in patients with GV in terms of the efficacy for secondary prevention of GV bleeding and effects on liver function.

METHODS

From our database of patients with GV who underwent EIS or BRTO between February 2011 and April 2020, a total of 42 patients with GV were retrospectively enrolled. The primary endpoint was the bleeding rate from GV, which was compared between EIS and BRTO groups. Secondary endpoints were liver function after treatment and rebleeding rate from EV, compared between EIS and BRTO groups. Rebleeding rates from GV and EV and liver function after treatment were also compared between EIS-ethanolamine oleate (EO)/histoacryl (HA) and EIS-HA groups.

RESULTS

Technical success was achieved for all EIS cases, but two cases were unsuccessful in the BRTO group and underwent additional EIS. No significant differences in bleeding rates or endoscopic findings for GV improvement were seen between EIS and BRTO groups. Liver function also showed no significant difference in the amount of change after treatment between groups.

CONCLUSION

EIS therapy appears effective for GV in terms of preventing GV rebleeding and effects on liver function after treatment. EIS appears to represent an effective treatment for GV.

A comprehensive review of transvenous obliteration techniques in the management of gastric varices

Bleeding gastric varices (GVs) is a life-threatening complication of portal hypertension, with higher morbidity and mortality rates compared with bleeding esophageal varices (EVs). The endovascular techniques for the management of GVs are mainly transjugular intrahepatic portosystemic shunt (TIPS) and transvenous obliteration of the GVs. Transvenous obliteration techniques can be an alternative or an adjunct to TIPS for treatment of GVs, depending on the clinical scenario, and are less invasive than TIPS. However, these procedures are associated with increased portal pressure and related complications, mainly worsening of the EVs. In this article, the different techniques of transvenous obliteration of GVs, their indications, contraindications, and outcomes are discussed.

Endoscopic ultrasound-guided diagnosis and treatment of gastric varices

Gastric varices (GV) represent a common and severe complication in patients with portal hypertension, commonly seen in patients with cirrhosis and severe pancreatic disease. Endoscopic ultrasonography is a safe and efficacious approach that can perform real-time ultrasonic scanning and intervention for the gastrointestinal submucosa, portal vein and its tributaries, and collateral circulations during direct endoscopic observation. Recently, various studies have been published about endoscopic ultrasound (EUS)-guided management of GV, mainly including diagnosis, treatment, and prognostic analysis. This article reviews published articles and guidelines to present the development process and current management of EUS-guided GV procedures.

Endoscopic ultrasound-guided diagnosis and treatment of gastric varices

Gastric varices (GV) represent a common and severe complication in patients with portal hypertension, commonly seen in patients with cirrhosis and severe pancreatic disease. Endoscopic ultrasonography is a safe and efficacious approach that can perform real-time ultrasonic scanning and intervention for the gastrointestinal submucosa, portal vein and its tributaries, and collateral circulations during direct endoscopic observation. Recently, various studies have been published about endoscopic ultrasound (EUS)-guided management of GV, mainly including diagnosis, treatment, and prognostic analysis. This article reviews published articles and guidelines to present the development process and current management of EUS-guided GV procedures.

Successful Percutaneous Transhepatic Obliteration Plus Sengstaken-Blakemore Tube Combination Therapy for Recurrent Gastroesophageal Variceal Bleeding: A Case Report

We treated a case of gastroesophageal varices due to decompensated liver cirrhosis associated with Wilson's disease. The varicose veins penetrated the paraesophageal vein. We performed endoscopic variceal ligation (EVL) on the perforating vein and endoscopic injection sclerotherapy (EIS) distally. However, 5 days after treatment, the patient vomited blood. Esophagogastroduodenoscopy showed bleeding from the ulcer after EVL at the perforating vein. We performed EVL and stopped the bleeding. However, the next day, she vomited blood again and developed hemorrhagic shock. We were able to achieve hemostasis and save the patient's life with combination therapy consisting of percutaneous transhepatic obliteration and Sengstaken-Blakemore tube placement.

Transjugular intrahepatic portosystemic shunt with or without gastro-oesophageal variceal embolisation for the prevention of variceal rebleeding: a randomised controlled trial

BACKGROUND

The role of variceal embolisation at the time of transjugular intrahepatic portosystemic shunt (TIPS) creation for the prevention of gastro-oesophageal variceal rebleeding remains controversial. This study aimed to evaluate whether adding variceal embolisation to TIPS placement could reduce the incidence of rebleeding after TIPS in patients with cirrhosis.

METHODS

We did an open-label, randomised controlled trial at one university hospital in China. Eligible patients were aged 18-75 years with cirrhosis and had variceal bleeding in the past 6 weeks, and they were randomly assigned (1:1) to receive TIPS (with a covered stent in both groups) plus variceal embolisation (TIPS plus embolisation group) or TIPS alone (TIPS group) to prevent variceal rebleeding. Randomisation was done using a web-based randomisation system using a Pocock and Simon's minimisation method, stratified by Child-Pugh class (A vs B vs C). Clinicians and patients were not masked to treatment allocation; individuals involved in data analysis were masked to treatment assignment. The primary endpoint was the 2-year cumulative incidence of variceal rebleeding after randomisation, and analysis was by intention to treat. The trial is registered with ClinicalTrials.gov, NCT02119988.

FINDINGS

Between June 16, 2014, and Feb 3, 2016, 205 patients were screened, of whom 134 were randomly allocated to the TIPS plus embolisation group (n=69) and the TIPS group (n=65). TIPS placement and variceal embolisation was successful in all 134 patients, all were included in the analysis. There was no significant difference in the 2-year cumulative incidence of variceal rebleeding between the two groups (TIPS plus embolisation 11·6% [95% CI 4·0-19·1] vs TIPS 13·8% [5·4-22·2]; hazard ratio 0·82 [95% CI 0·42-1·61]; p=0·566). Adverse events were similar between the two groups; the most common adverse events were peptic ulcer or gastritis (12 [17%] of patients in the TIPS plus embolisation group vs 13 [20%] of patients in the TIPS group), new or worsening ascites (ten [14%] vs six [9%]), and hepatocellular carcinoma (four [6%] vs six [9%]). The numbers of deaths were also similar between groups (24 [35%] vs 25 [38%]) INTERPRETATION: Adding variceal embolisation to TIPS did not significantly reduce the incidence of variceal rebleeding in patients with cirrhosis. Our findings do not support concomitant variceal embolisation during TIPS for the prevention of variceal rebleeding.

FUNDING

National Key Technology R&D Program, Boost Program of Xijing Hospital, and China Postdoctoral Science Foundation.

Management of Portal Hypertension

Portal hypertension is the cause of the clinical complications associated with cirrhosis. The primary complications of portal hypertension are ascites, acute variceal bleed, and hepatic encephalopathy. Hepatic venous pressure gradient measurement remains the gold standard test for diagnosing cirrhosis-related portal hypertension. Hepatic venous pressure gradient more than 10 mmHg is associated with an increased risk of complications and is termed clinically significant portal hypertension (CSPH). Clinical, laboratory, and imaging methods can also aid in diagnosing CSPH non-invasively. Recently, deep learning methods have been demonstrated to diagnose CSPH effectively. The management of portal hypertension is always individualized and is dependent on the etiology, the availability of therapies, and the degree of portal hypertension complications. In this review, we discuss the diagnosis and management of cirrhosis-related portal hypertension in detail. Also, we highlight the history of portal hypertension and future research areas in portal hypertension.

Emergent Transjugular Intrahepatic Portosystemic Shunt Creation for Acute Gastric Variceal Bleeding in Patients with Hepatocellular Carcinoma

A total of 42 cirrhotic patients (mean age, 51.7 years ± 10.8; 38 men) with hepatocellular carcinoma who underwent emergent transjugular intrahepatic portosystemic shunt (TIPS) creation for controlling acute gastric variceal bleeding (GVB) were included in this multicenter retrospective study. Of these, 37 (88.1%) patients underwent emergent TIPS creation as the first-line treatment to control acute GVB. Five (11.9%) patients underwent emergent TIPS creation as a rescue/salvage treatment to control acute GVB after emergent endoscopic therapy and pharmacotherapy. Emergent TIPS creation was technically successful in 40 (95.2%) patients. Two (4.8%) patients had severe and moderate procedural adverse events. The median follow-up duration was 16.9 months (range, 0.1-100.8 months). Failure to control acute bleeding and failure to prevent rebleeding occurred in 8 (19.0%) patients during follow-up. Eighteen (42.9%) patients died during follow-up. Three (7.1%) patients had shunt dysfunction during follow-up. Overt hepatic encephalopathy occurred in 6 (14.3%) patients during follow-up.

Progress in Endoscopic and Interventional Treatment of Esophagogastric Variceal Bleeding

Esophagogastric variceal bleeding (EGVB) is one of the main complications of portal hypertension, especially in patients with liver cirrhosis, and has a very high fatality rate. At present, the treatment methods for rupture and bleeding of gastroesophageal varices (GV) include drug therapy, compression hemostasis with three-lumen and two-balloon tube, endoscopic therapy, and interventional and surgical operations. Endoscopy and intervention or their combined application is the mainstream treatment modes in clinical practice, especially their combined application has been increasingly recognized by front-line clinicians. This article intends to discuss the application characteristics of the two treatment methods.

Safety and Efficacy of Thrombin for Bleeding Gastric Varices: A Systematic Review and Meta-Analysis

INTRODUCTION

The optimal therapy for bleeding-related gastric varices is still a controversial topic. There is a paucity of literature that comprehensively summarizes the available literature regarding safety and efficacy of thrombin in bleeding gastric varices.

METHODS

Four independent reviewers performed a comprehensive review of all original articles published from inception to October 2020, describing the use of thrombin for management of bleeding gastric varices. Primary outcomes were (1) pooled early and late rebleeding rate, (2) pooled gastric variceal related mortality rate, (3) pooled rescue therapy rate, and (4) pooled adverse event rate with the use of thrombin in bleeding gastric varices. The meta-analysis was performed and the statistics were two-tailed. Finally, probability of publication bias was assessed using funnel plots and with Egger's test.

RESULTS

Eleven studies were included in the analysis after comprehensive search. This yielded a pooled early rebleeding rate of 9.3% (95% CI 4.9-17) and late rebleeding rate 13.8% (95% CI 9-20.4). Pooled rescue therapy rate after injecting thrombin in bleeding gastric varices was 10.1% (95% CI 6.1-16.3). The pooled 6-week gastric variceal-related mortality rate after injecting thrombin in bleeding gastric varices was 7.6% (95% CI 4.5-12.5). There were a total of four adverse events out of a total of 222 patients with pooled adverse event rate after injecting thrombin in bleeding gastric varices was 5.6% (95% CI 2.9-10.6).

CONCLUSION

In summary, the systematic review and meta-analysis on the use of thrombin for bleeding gastric varices suggest low rates of rebleeding and minimal rates of adverse events. While, early and late rebleeding rate and rescue therapy rate are similar to cyanoacrylate-based therapy, the minimal rates of adverse events are perhaps the most important benefit of thrombin. Thus, the current data suggest that thrombin is a very promising therapeutic alternative with low risk of adverse events for bleeding gastric varices.

Safety and efficacy of endoscopic ultrasound-guided combination therapy for treatment of gastric varices: a systematic review and meta-analysis

BACKGROUND

EUS-guided combination therapy (coil and hemostatic glue) for bleeding and non-bleeding gastric varices has recently attracted considerable attention after promising results were published in multiple small studies. We performed a meta-analysis to investigate the safety and efficacy of EUS-guided combination therapy in the treatment of GVs.

METHODS

Publications investigating the safety and efficacy of EUS-guided combination therapy in patients with gastric varices were searched in Medline, Ovid Journals, Medline non-indexed citations and Cochrane Central Register of Controlled Trials. Pooling was conducted by both fixed and random effects model.

RESULTS

In pooled analysis of 10 studies (N = 323), the technical success of EUS-guided combination therapy was 98.66% (95% CI 97.14-99.62). The pooled variceal obliteration rate after first session of treatment was 78.31% (95% CI 73.05-83.14). In patients requiring single or multiple treatment sessions, the overall variceal obliteration rate was 96.79% (95% CI 94.28-98.60). The pooled rate of hemorrhage from treated gastric varices was 4.92% (95% CI 2.85-7.52). After EUS-guided combination therapy, the pooled percentage of patients developing abdominal pain was 9.79% (95% CI 6.82-13.24), pulmonary embolism was 2.20% (95% CI 0.89-4.06), febrile episodes was 1.17% (95% CI 0.30-2.61), and procedure-related bleeding was noted in 2.62% (95% CI 1.18-4.63) of the patients. Subgroup analysis of studies using coil embolization and cyanoacrylate injection showed pooled variceal obliteration rate of 77.92% (95% CI 72.35-83.01) after first session of treatment. In patients requiring single or multiple treatment sessions, the overall variceal obliteration rate was 96.76% (95% CI 94.11-98.65). The pooled rate of re-bleeding from treated gastric varices was 5.09% (95% CI 2.90-7.83).

CONCLUSIONS

This meta-analysis suggests that EUS-guided combination therapy is safe and effective for patients with gastric varices and should be considered in the clinical management of these patients.

A meta-analysis of combined generic-covered stent-graft with or without bare-metal stent for refractory variceal bleeding

Objectives:

The meta-analysis was conducted to systematically assess the efficacy and safety of generic stent-graft/bare-stent combination compared with Fluency stent alone in transjugular intrahepatic portosystemic shunt procedure for refractory variceal bleeding.

Methods:

PubMed, EMBASE, Scopus, Web of Science and the Cochrane Database were searched for relevant studies from January 1990 to September 2020; outcome measures studied were primary patency, hepatic encephalopathy, survival, re-bleeding and portal venous pressure.

Results:

Four studies (1 randomised controlled trial and 3 retrospective studies) with 449 subjects (157 patients in the combined stent group and 292 patients in the covered stent group) were included. No significant difference was observed in the incidence of mortality (hazard ratio [HR] = 1.069, 95% confidence interval [CI] [0.524, 2.178]), hepatic encephalopathy (odds ratio [OR] = 0.860, 95% CI [0.341, 2.169], P = 0.750) and re-bleeding (OR = 1.049, 95% CI [0.226, 4.881], P = 0.951). Compared with Fluency stent alone, combination therapy was associated with moderate decrease in outcomes on the post-operative portal venous pressure (standard mean difference [SMD] −0.210, 95% CI [−0.418, −0.001], P = 0.049) and was not associated with significant decrease in outcomes on the pre-operative portal venous pressure (SMD − 0.129, 95% CI [−0.336, 0.078], P = 0.223). The primary patency was significantly lower in the Fluency/bare-stent combination group (HR = 0.473, 95% CI [0.288, 0.776]).

Conclusions:

Generic stent-graft/bare-stent combination therapy was associated with significantly lower primary patency compared to Fluency stent alone.

Endoscopic Cyanoacrylate Injection Versus Balloon-Occluded Retrograde Transvenous Obliteration for Prevention of Gastric Variceal Bleeding: A Randomized Controlled Trial

BACKGROUND AND AIMS

The optimal treatment for gastric varices (GVs) is a topic that remains open for study. This study compared the efficacy and safety of endoscopic cyanoacrylate injection and balloon-occluded retrograde transvenous obliteration (BRTO) to prevent rebleeding in patients with cirrhosis and GVs after primary hemostasis.

APPROACH AND RESULTS

Patients with cirrhosis and history of bleeding from gastroesophageal varices type 2 or isolated gastric varices type 1 were randomized to cyanoacrylate injection (n = 32) or BRTO treatment (n = 32). Primary outcomes were gastric variceal rebleeding or all-cause rebleeding. Patient characteristics were well balanced between two groups. Mean follow-up time was 27.1 ± 12.0 months in a cyanoacrylate injection group and 27.6 ± 14.3 months in a BRTO group. Probability of gastric variceal rebleeding was higher in the cyanoacrylate injection group than in the BRTO group (P = 0.024). Probability of remaining free of all-cause rebleeding at 1 and 2 years for cyanoacrylate injection versus BRTO was 77% versus 96.3% and 65.2% versus 92.6% (P = 0.004). Survival rates, frequency of complications, and worsening of esophageal varices were similar in both groups. BRTO resulted in fewer hospitalizations, inpatient stays, and lower medical costs.

CONCLUSIONS

BRTO is more effective than cyanoacrylate injection in preventing rebleeding from GVs, with similar frequencies of complications and mortalities.

Safety and efficacy of endoscopic cyanoacrylate injection in the management of gastric varices: A systematic review and meta-analysis

BACKGROUND AND AIM

Bleeding from gastric varices is a catastrophic event and poses difficulty in management. The efficacy and safety of cyanoacrylate injection remain unclear. We performed a systematic review and meta-analysis to evaluate the effect of endoscopic cyanoacrylate injection in the management of gastric varices.

METHODS

We conducted a comprehensive search of MEDLINE, Embase, Web of Science, Scopus databases, and Cochrane Database of Systematic Reviews through November 2020 and manually reviewed the literature. Trial-specific risk ratios (RRs) were estimated and pooled using random-effect model meta-analysis.

RESULTS

We included seven randomized controlled trials (six for secondary prophylaxis and one for primary prophylaxis) at low risk of bias in which 126 deaths were reported among 583 patients with gastric varices. All studies reported the use of N-butyl-2-cyanoacrylate glue. Cyanoacrylate use was associated with significantly lower all-cause mortality (RR, 0.59; 95% confidence interval [CI], 0.36-0.98; I2 = 41%) and rebleeding rate after hemostasis (RR, 0.49; 95% CI, 0.35-0.68, I2 = 0%) compared with any other treatment approach not involving cyanoacrylate. When cyanoacrylate was compared with each individual treatment approach (propranolol only, band ligation, sclerotherapy with alcohol or ethanolamine), data comprised sparse limited comparative conclusions. The use of cyanoacrylate injection was not associated with an increase in serious adverse events. The quality of evidence is moderate, graded down due to the small number of events and wide CIs.

CONCLUSION

The use of endoscopic cyanoacrylate injection therapy for gastric varices may be associated with lower all-cause mortality and better hemostasis compared with other therapies.

Unpacking the challenge of gastric varices: A review on indication, timing and modality of therapy

Upper gastrointestinal bleeding from oesophageal or gastric varices is an important medical condition in patients with portal hypertension. Despite the emergence of a number of novel endoscopic and radiologic therapies for oesophagogastric varices, controversy exists regarding the indication, timing and modality of therapy. The aim of this review is to provide a concise and practical evidence-based overview of these issues.

Friend or Foe? Spontaneous Portosystemic Shunts in Cirrhosis-Current Understanding and Future Prospects

Portal hypertension (PHT) in cirrhosis results from increased resistance to splanchnic blood flow secondary to parenchymal and vascular changes within the liver. In an attempt to counteract the increased portal pressure, two mechanisms simultaneously occur: splanchnic vasodilatation and formation of spontaneous portosystemic shunts (SPSS). Long considered to be a compensatory mechanism to decompress the portal venous system, it is now well established that SPSS are not only inefficient in decreasing the portal pressure but also contribute to reduced hepatocyte perfusion and increased splanchnic blood flow and resistance, associated with worsening PHT. Recent studies have described a high prevalence of SPSS in cirrhosis patients, increasing with liver dysfunction, and observed an association between the presence of SPSS and worse clinical outcomes. In cirrhosis patients with preserved liver functions, the presence of SPSS independently increases the risk of hepatic encephalopathy, variceal bleeding, and ascites, and reduces transplant-free survival. Moreover, the presence of SPSS in patients undergoing transjugular intrahepatic portosystemic shunting and liver transplant has been shown to variably affect the postprocedural outcome. This article provides an overview of the current understanding of the role of SPSS in the natural history of liver cirrhosis and their status as a therapeutic target and an imaging biomarker to identify patients at higher risk of developing complications of PHT.

AGA Clinical Practice Update on Management of Bleeding Gastric Varices: Expert Review

Management of bleeding gastric varices (GV) presents a unique challenge for patients with portal hypertension. Despite over thirty years of diagnostic and treatment advances standardized practices for bleeding GV are lacking and unsupported by adequate evidence. There are no definitive natural history studies to help with risk assessment or prospective clinical trials to guide clinical decision making. Available literature on the natural history and management of gastric varices consists of case series, restricted cohort studies, and a few small randomized trials, all of which have significant selection biases. This review summarizes the available data and recommendations based on expert opinion on how best to diagnose and manage bleeding from gastric varices. Table 1 summarizes our recommendations.

Primary prophylaxis of gastric variceal bleeding: endoscopic obturation, radiologic intervention, or observation?

BACKGROUND

No single effective method has yet been established for the primary prophylaxis of bleeding from gastric varices (GV).

METHODS

We retrospectively analyzed liver cirrhosis patients with GV who had undergone either endoscopic variceal obturation (EVO) or balloon-occluded retrograde transvenous obliteration (BRTO) as prophylactic treatments, comparing them with those who were observed without any procedural intervention. The endpoints were GV bleeding rate and complete eradication rate.

RESULTS

72 patients in EVO, 41 patients in BRTO, and 97 patients in the clinical observation groups were enrolled. No difference was observed in baseline characteristics. As the primary endpoint, 14 (19.4%) patients in the EVO group and 3 (7.3%) in the BRTO group bled from GV after prophylactic treatment, and 34 (35.1%) patients bled in the observation group during the median follow-up of 35 months (p = 0.001). Patients who received EVO or BRTO developed less bleeding from GV than those who received observation only, with no difference between EVO and BRTO (EVO vs. observation, p = 0.038; BRTO vs. observation, p = 0.001; EVO vs. BRTO, p = 0.089). As secondary endpoints, GV disappeared completely in 33 patients (45.8%) in the EVO group and 31 patients (75.6%) in the BRTO group (p = 0.003). By multivariate analysis, complete eradication of GV was the sole determinant for predicting GV bleeding.

CONCLUSIONS

EVO and BRTO are effective and safe primary prophylactic treatments for preventing bleeding from GV. In particular, BRTO is better than EVO in complete eradication of GV.

Management of portal hypertension severe complications

Portal hypertension is a clinical syndrome characterized by an increase in the portal pressure gradient, defined as the gradient between the portal vein at the site downstream of the site of obstruction and the inferior vena cava. The most frequent cause of portal hypertension is cirrhosis. In patients with cirrhosis, portal hypertension is the main driver of cirrhosis progression and development of hepatic decompensation (ascites, variceal hemorrhage and hepatic encephalopathy), which defines the transition from compensated to decompensated stage. In decompensated patients, treatments aim at lowering the risk of death by preventing further decompensation and/or development of acute-on-chronic liver failure. Decompensated patients often pose a complex challenge which typically requires a multidisciplinary approach. The aims of the present review were to discuss the current knowledge regarding interventional treatments for patients with portal hypertension complications as well as to highlight useful information to aid hepatologists in their clinical practice. Specifically, we discussed the indications and contraindications of transjugular intra-hepatic portosystemic shunt and for the treatment of gastro-esophageal variceal hemorrhage in patients with decompensated cirrhosis (first section); we reviewed the use of interventional treatments in patients with hepatic vein obstruction (Budd-Chiari Syndrome) and in those with portal vein thrombosis (second section); and we briefly comment on the most frequent applications of selective splenic embolization in patients with and without underlying cirrhosis (third section).

Combined Transjugular Intrahepatic Portosystemic Shunt Plus Variceal Obliteration versus Transjugular Intrahepatic Portosystemic Shunt Alone for the Management of Gastric Varices: Comparative Single-Center Clinical Outcomes

PURPOSE

To compare the safety and clinical outcomes of combined transjugular intrahepatic portosystemic shunt (TIPS) plus variceal obliteration to those of TIPS alone for the treatment of gastric varices (GVs).

MATERIALS AND METHODS

A single-center, retrospective study of 40 patients with bleeding or high-risk GVs between 2008 and 2019 was performed. The patients were treated with combined therapy (n = 18) or TIPS alone (n = 22). There were no significant differences in age, sex, model for end-stage liver disease score, or GV type between the groups. The primary outcomes were the rates of GV eradication and rebleeding. The secondary outcomes included portal hypertensive complications and hepatic encephalopathy.

RESULTS

The mean follow-up period was 15.4 months for the combined therapy group and 22.9 months for the TIPS group (P = .32). After combined therapy, there was a higher rate of GV eradication (92% vs 47%, P = .01) and a trend toward a lower rate of GV rebleeding (0% vs 23%, P = .056). The estimated rebleeding rates were 0% versus 5% at 3 months, 0% versus 11% at 6 months, 0% versus 18% at 1 year, and 0% versus 38% at 2 years after combined therapy and TIPS, respectively (P = .077). There was no difference in ascites (13% vs 11%, P = .63), hepatic encephalopathy (47% vs 55%, P = .44), or esophageal variceal bleeding (0% vs 0%, P > .999) after the procedure between the groups.

CONCLUSIONS

The GV eradication rate is significantly higher after combined therapy, with no associated increase in portal hypertensive complications. This translates to a clinically meaningful trend toward a reduction in GV rebleeding. The value of a combined treatment strategy should be prospectively studied in a larger cohort to determine the optimal management of GVs.

Balloon-Occluded Retrograde Transvenous Obliteration (BRTO) Versus Transjugular Intrahepatic Portosystemic Shunt (TIPS) for Treatment of Gastric Varices Because of Portal Hypertension: A Systematic Review and Meta-Analysis

BACKGROUND

Although gastric variceal (GV) bleeding is less common than esophageal variceal bleeding, the severity of GV bleeding is often greater with higher morbidity and mortality rates. Minimally invasive endovascular treatments such as balloon-occluded retrograde transvenous obliteration (BRTO) and transjugular intrahepatic portosystemic shunt (TIPS) have been used for the management of GVs with varying results, and individual and institutional differences exist in the use of BRTO and TIPS. We performed a systematic review and meta-analysis to compare the feasibility, efficacy, and safety of BRTO and TIPS for the treatment of GVs because of portal hypertension.

METHODS

Searches of PubMed, EMBASE, Google Scholar, and Cochrane Library databases were performed from inception through March 2019. Summary odds ratio (OR) with 95% confidence intervals (CI) was estimated for technical success, hemostasis rate, postprocedural complications, rebleeding rate, incidence of hepatic encephalopathy, and mortality rate at 1 year utilizing a random-effects model.

RESULTS

Seven studies with a total of 676 patients (BRTO: 462 and TIPS: 214) were included. There was no difference in pooled technical success rate (OR, 0.87; 95% CI, 0.28-2.73; P=0.81), hemostasis rate (OR, 2.74; 95% CI, 0.61-12.26; P=0.19), and postoperative procedure-related complications (OR, 1.95; 95% CI, 0.44-8.72; P=0.38). However, treatment with BRTO was associated with lower rates of postoperative rebleeding (OR, 0.30; 95% CI, 0.18-0.48; P<0.00001), postoperative encephalopathy (OR, 0.06; 95% CI, 0.02-0.15; P < 0.00001), and mortality at 1 year (OR, 0.43; 95% CI, 0.21-0.87; P=0.02).

CONCLUSIONS

BRTO was associated with lower rates of rebleeding, postprocedure hepatic encephalopathy, and mortality at 1 year. BRTO should be considered first-line modality for the treatment of GVs because of portal hypertension.

Emergent Transjugular Intrahepatic Portosystemic Shunt Creation in Acute Variceal Bleeding

Emergent transjugular intrahepatic portosystemic shunt (TIPS) creation is most commonly employed in the setting of acute variceal hemorrhage. Given a propensity for decompensation, these patients often require a multidisciplinary, multimodal approach involving prompt diagnosis, pharmacologic therapy, and endoscopic intervention. While successful in the majority of cases, failure to medically control initial bleeding can prompt interventional radiology consultation for emergent portal decompression via TIPS creation. This article discusses TIPS creation in emergent, acute variceal hemorrhage, reviewing the natural history of gastroesophageal varices, presentation and diagnosis of acute variceal hemorrhage, pharmacologic therapy, endoscopic approaches, patient selection and risk stratification for TIPS, technical considerations for TIPS creation, adjunctive embolotherapy, and the role of salvage TIPS versus early TIPS in acute variceal hemorrhage.

Comparison of the Effects of TIPS versus BRTO on Bleeding Gastric Varices: A Meta-Analysis

Background and Aim. Upper gastrointestinal bleeding is a threat to patients with gastric varices (GVs). Previous studies have concluded that both transjugular intrahepatic portosystemic shunt (TIPS) and balloon-occluded retrograde transvenous obliteration (BRTO) are effective treatments for patients with GV. We aimed to compare the efficiency and outcomes of these two procedures in GV patients through meta-analysis.

METHODS

The PubMed, Cochrane Library, EMBASE, and Web of Science databases were searched using the keywords: GV, bleeding, TIPS, and BRTO to identify relevant randomized controlled trials and cohort studies. The overall survival (OS) rate, imminent haemostasis rate, rebleeding rate, technical success rate, procedure complication rate (hepatic encephalopathy and aggravated ascites), and Child-Pugh score were evaluated. Randomized clinical trials and cohort studies comparing TIPS and BRTO for GV due to portal hypertension were included in our meta-analysis. Two independent reviewers performed data extraction and assessed the study quality. A meta-analysis was performed to calculate risk ratios (RRs), mean differences (MDs), and 95% CIs using random effects models.

RESULTS

A total of nine studies fulfilled the inclusion criteria. There was a significant difference between TIPS and BRTO in the OS rate (RR, 0.81 (95% CI, 0.66 to 0.98); P=0.03) and rebleeding rate (RR, 2.61 (95% CI, 1.75 to 3.90); P=0.03) and rebleeding rate (RR, 2.61 (95% CI, 1.75 to 3.90); P=0.03) and rebleeding rate (RR, 2.61 (95% CI, 1.75 to 3.90); P=0.03) and rebleeding rate (RR, 2.61 (95% CI, 1.75 to 3.90); P=0.03) and rebleeding rate (RR, 2.61 (95% CI, 1.75 to 3.90); P=0.03) and rebleeding rate (RR, 2.61 (95% CI, 1.75 to 3.90); P=0.03) and rebleeding rate (RR, 2.61 (95% CI, 1.75 to 3.90).

CONCLUSIONS

In this meta-analysis, BRTO brought more benefits to patients, with a higher OS rate and lower rebleeding rate. BRTO is a feasible method for GVB.

Combination therapy versus monotherapy for EUS-guided management of gastric varices: A systematic review and meta-analysis

Cyanoacrylate (CYA), coil embolization, and/or combination thereof are available EUS-guided therapies for the treatment of gastric varices (GV). The primary aim of this study was to perform a structured systematic review and meta-analysis to evaluate the comparative effectiveness of EUS-guided interventions for the treatment of GV. Individualized search strategies were developed for PubMed, EMBASE, and Cochrane Library databases, from inception through November 2018 in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. This cumulative meta-analysis was performed using calculating pooled proportions. Measured outcomes included technical success, clinical success, adverse events, and rate of rebleeding or reintervention. Comparative subgroup analyses were performed for three treatment cohorts (EUS-guided CYA injection, EUS-guided coil embolization + CYA injection, and EUS-guided coil injection alone). Heterogeneity was assessed with I² statistics. Eleven studies (n = 536 patients; 62.20% of males) were included. The mean age was 58.21 ± 4.15 years with an average follow-up of 12.93 ± 7.69 months. Overall technical success, clinical success, and adverse events for EUS treatments was 100% ([95% confidence interval [CI] 98–100]; I² = 30.54%), 97% ([95% CI 92–100]; I² = 59.99%), and 14% ([95% CI 6–23]; I² = 82.23%), respectively. On subgroup analysis, EUS-guided CYA + coil embolization resulted in a better technical and clinical success compared to CYA alone (100% vs. 97%; P < 0.001 and 98% vs. 96%; P < 0.001) and coil embolization alone (99% vs. 97%; P < 0.001 and 96% vs. 90%; P < 0.001). CYA + coil embolization also resulted in lower adverse event rates compared to CYA alone (10% vs. 21%; P < 0.001), and comparable rates to coil embolization alone (10% vs. 3%; P = 0.057). EUS-guided treatment overall appears to be an effective and safe modality for GV. Among a variety of EUS-therapies available, EUS combination therapy with coil embolization + CYA injection appears to be a preferred strategy for the treatment of GV over EUS-based monotherapy.

Addition of Carvedilol to Gastric Variceal Obturation Does Not Decrease Recurrence of Gastric Variceal Bleeding in Patients With Cirrhosis

BACKGROUND & AIMS

Gastric variceal bleeding (GVB) frequently recurs after hemostasis by gastric variceal obturation (GVO). We performed a multicenter, randomized controlled trial to determine the efficacy of carvedilol plus GVO in secondary prophylaxis of GVB.

METHODS

We performed a prospective study of 121 patients with cirrhosis (ages 20-80 years) with GVB proven by endoscopy within 24 hours of bleeding and stable hemodynamics for at least 3 days after initial GVO. Patients were randomly assigned into a group that underwent repeated GVO (n = 61) or a group received repeated GVO plus carvedilol (n = 60). Recurrent GVB, upper gastrointestinal bleeding (UGIB), adverse events, and survival were compared between the groups.

RESULTS

GVB recurred in 21 patients (34%) in the group that received repeated GVO and 14 patients (23%) in the group that received repeated GVO plus carvedilol (P = .18). Ascites (relative risk [RR], 2.69; 95% CI, 1.33-5.48; P = .006) and hepatoma (RR, 2.10; 95% CI, 1.03-4.28; P = .04) were associated with recurrent GVB. Twenty-nine patients (48%) in the group that received repeated GVO and 17 patients (28%) in the group that received repeated GVO plus carvedilol had recurrent UGIB (P = .03). Carvedilol (RR, 0.44; 95% CI, 0.24-0.80; P = .007) was associated with reduced risk of UGIB recurrence. Ascites (RR, 3.02; 95% CI, 1.59-5.73; P = .001) and hepatoma (RR, 2.07; 95% CI, 1.10-3.88; P = .02) were associated with recurrent UGIB. A higher proportion of patients in the group that received repeated GVO plus carvedilol (53%) had adverse events than the group that received repeated GVO (15%) (P < .001). Mean survival times were 21 ± 18 months in the group that received repeated GVO vs 25 ± 20 months in the group that received repeated GVO plus carvedilol (P = .30).

CONCLUSION

In a randomized controlled trial, we found that addition of carvedilol to GVO did not decrease recurrence of GVB in patients with cirrhosis but was associated with decreased recurrence of UGIB. However, carvedilol plus GVO produced significantly more adverse events. Mean survival times did not differ significantly between groups. ClinicalTrials.gov no: NCT02504723.

Update on management of gastric varices

Gastric varices (GV) have different physiology and clinical characteristics compared to oesophageal varices (OV). There is little information about the management of GV. Most part of the recommendations is extrapolated from studies where the majority of participants had OV. Thus, most recommendations lack of strong evidence. This is a comprehensive review on all aspects of management of GV, i.e., primary, secondary prophylaxis and management of acute bleeding. The papers on which international societies' recommendations are based are scrutinised in this review and areas of research are identified.

Endoscopic ultrasound-guided injection of coils and cyanoacrylate glue for the treatment of gastric fundal varices with abnormal shunts: a series of case reports

Gastric varices are found in approximately 20% of patients with portal hypertension. Endoscopic procedures involving the injection of cyanoacrylate (CYA) have proven to be the therapies of choice for primary treatment of gastric varices and have resulted in higher hemostasis rates and lower recurrent bleeding rates compared with band ligation and sclerotherapy. Nevertheless, serious adverse events associated with CYA injection, including glue embolization, have been reported in numerous articles and have occasionally led to fatal adverse events. Gastric fundal varices with abnormal shunts are higher-risk than those without abnormal shunts, and their treatment is more challenging. Endoscopic ultrasound (EUS)-guided puncture is an important technique in the field of digestive endoscopy. EUS has advantages that include improved therapeutic targeting, enhanced variceal detection, the ability to confirm varix obliteration with Doppler examination, and the ability to perform accurate observations of gastric varices that are not affected by blood in the stomach. The coils currently used for intravascular embolization can be precisely delivered into a varix through fine-needle puncture under EUS guidance, and this technique has provided a new approach for varix obliteration. We herein describe two patients with severe gastric fundal varices who were treated with EUS-guided coil injection and CYA embolization.

Variable efficacy of TIPSS in the management of ectopic variceal bleeding: a multicentre retrospective study

BACKGROUND

Evidence for the efficacy of TIPSS in ectopic variceal bleeding (EctVB) is largely based on relatively small series.

AIM

To define the efficacy of TIPSS in EctVB.

METHODS

Retrospective analysis of consecutive patients with chronic liver disease who presented with EctVB and received TIPSS in three tertiary centres in 1992-2016.

RESULTS

The study included 53 patients (70% male, median age 61 years, median model for end-stage liver disease (MELD) score 11). The ectopic varices were located around the insertion of stomas (40%), duodenum (23%), rectum (17%) and at other sites (20%). Three-quarters of the patients had previously received unsuccessful medical, endoscopic or surgical therapy. The median follow-up was 14.0 months. Following TIPSS, bleeding recurred in 12 patients: 6 of 12 (50%) with duodenal varices, 2 of 9 (22%) with rectal varices and one each with stomal (1/21), intraperitoneal (1/3), hepaticojejunostomy (1/2) and ascending colon varices (1/2). The risk factors for re-bleeding were MELD score at TIPSS placement (HR: 1.081 per point; 95% confidence interval (CI): 1.012-1.153; P = 0.034), varices located at site other than an enterostomy (HR: 9.770; 95%CI: 1.241-76.917; P = 0.030) and previous local therapy (HR: 5.710; 95%CI: 1.211-26.922; P = 0.028). The estimated cumulative re-bleeding rate was 23% at 1 year, 26% at 3 years and 32% at 5 years. Post-TIPSS hepatic encephalopathy manifested or worsened in 16 of 53 patients (30%).

CONCLUSION

TIPSS provides long-term control of bleeding in most cirrhotic patients with EctVB. TIPSS is particularly effective in stomal EctVB, the most frequent cause of EctVB, but might not be as effective in duodenal EctVB.

Endovascular Treatment for Variceal Hemorrhage: TIPS, BRTO, and Combined Approaches

Variceal hemorrhage is a feared complication of portal hypertension, with high rates of morbidity and mortality. Optimal management requires a thoughtful, multidisciplinary approach. In cases of refractory or recurrent esophageal hemorrhage, endovascular approaches such as transjugular intrahepatic portosystemic shunt (TIPS) have a well-defined role. For hemorrhage related to gastric varices, the optimal treatment remains to be established; however, there is increasing adoption of balloon-occluded retrograde transvenous obliteration (BRTO). This article will review the concept, history, patient selection, basic technique, and outcomes for TIPS, BRTO, and combined TIPS + BRTO procedures for variceal hemorrhage.

Comparison of transjugular intrahepatic portosystemic shunt (TIPS) alone and combined with embolisation for the management of cardiofundal varices: a retrospective study

OBJECTIVES

To assess the efficacy of transjugular intrahepatic portosystemic shunt (TIPS) with and without adjunctive embolisation in managing cardiofundal varices bleeding.

METHODS

The retrospective study comprised 82 patients (54 men; mean age 53.9 years; mean Model of End-stage Liver Disease score 9.3) with cardiofundal varices bleeding who underwent TIPS creation from 2011 to 2015. Variceal rebleeding, the outflow tracts of varices, overt hepatic encephalopathy (HE) and post-procedure varices patency were assessed.

RESULTS

Gastrorenal shunt was present in 92.7% of patients (n = 76). Embolisation was performed in 67.1% of patients (n = 55). The 1- and 2-year variceal rebleeding rates in the TIPS combined with embolisation group were significantly lower than those in the TIPS alone group (3.8% and 13.4% vs 13.0% and 28.0%, respectively; p = 0.041). No significant differences between the two groups were found in the cardiofundal varices patency, overt HE or survival (p > 0.05).

CONCLUSIONS

The results suggest that TIPS combined with embolisation can reduce the risk of variceal rebleeding for patients with cardiofundal varices.

KEY POINTS

• TIPS combined with embolisation reduces the risk of rebleeding in treating cardiofundal varices. • TIPS combined with embolisation could not completely occlude cardiofundal varices. • TIPS combined with embolisation could not prevent the development of hepatic encephalopathy.

Comparison of treatment outcomes between balloon-occluded retrograde transvenous obliteration and transjugular intrahepatic portosystemic shunt for gastric variceal bleeding hemostasis

BACKGROUND AND AIM

Both balloon-occluded retrograde transvenous obliteration (BRTO) and transjugular intrahepatic portosystemic shunt (TIPS) are considered effective treatments for gastric variceal bleeding (GVB). In this study, outcomes of these two procedures were compared in managing patients with GVB.

METHODS

A total of 142 patients undergoing BRTO (n = 95) or TIPS (n = 47) between 2005 and 2012 at two tertiary centers were selected for retrospective review.

RESULTS

Mean patient age (male, 115; female, 27) was 58.1 years. Alcoholic liver cirrhosis was the most common underlying cause (n = 63, 44.4%), followed by hepatitis B (n = 60, 42.3%) and hepatitis C (n = 7, 4.9%) viral infections. Concurrent hepatocellular carcinoma (HCC) was identified in 64 (45.1%) patients. During the follow-up period (mean, 28.2 months), 27 patients (19%) experienced re-bleeding. Cumulative re-bleeding rates after BRTO (8.6% at 1 year; 22.7% at 3 years) were significantly lower than those after TIPS (19.8% at 1 year; 48.2% at 3 years; P = 0.006, log-rank test). In multivariate analysis, TIPS (vs BRTO) was found independently predictive of re-bleeding (hazard ratio [HR] = 2.174; P = 0.048), in addition to concurrent HCC and poor baseline Child-Pugh score (both P < 0.05). Although BRTO surpassed TIPS (P = 0.026, log-rank test) in terms of overall postprocedural survival, independent factors predictive of poor overall survival after hemostasis were concurrent HCC (HR = 3.106), high Child-Pugh score (HR = 1.886 per 1-point increase), and postprocedural hepatic encephalopathy (HR = 3.014; all P < 0.05).

CONCLUSION

Balloon-occluded retrograde transvenous obliteration proved more effective than TIPS in hemostasis of GVB, associated with significantly less risk of re-bleeding.

Customization of laparoscopic gastric devascularization and splenectomy for gastric varices based on CT vascular anatomy

BACKGROUND

Laparoscopic gastric devascularization(Lap GDS) and splenectomy (SPL) for gastric varices is technically challenging because of highly developed collateral vessels and bleeding tendency. We investigated the feasibility of customization of Lap GDS and SPL based on CT vascular anatomy.

METHODS

We analyzed 61 cirrhotic patients with gastric varices who underwent Lap GDS and SPL between 2006 and 2014. Lap GDS was customized according to the afferent feeding veins (left gastric vein (LGV) and/or posterior gastric vein (PGV)/short gastric vein (SGV)) and efferent drainage veins (gastrorenal shunt and/or gastrophrenic shunt, or numerous retroperitoneal veins) based on CT imaging.

RESULTS

Thirty-four patients with efferent drainage veins suitable for balloon-occluded retrograde transvenous obliteration (B-RTO) underwent B-RTO instead of surgical GDS, with subsequent Lap SPL. Among 27 patients with gastric varices unsuitable for B-RTO, 15 patients with PGV/SGV underwent Lap GDS of the greater curvature and SPL, and 12 patients with LGV or LGV/PGV/SGV underwent Lap GDS of the greater and lesser curvature and SPL. The mean operation time was 294 min and mean blood loss was 198 g. There was no mortality or severe morbidity. Gastric varices were eradicated in all 61 patients, with no bleeding or recurrence during a mean follow-up of 55.9 months. The cumulative 3-, 5-, and 7-year survival rates were 92, 82, and 64%, respectively.

CONCLUSIONS

Lap GDS and SPL customized based on CT vascular anatomy is a safe and effective procedure for treating gastric varices.

Recent advances in the management of variceal bleeding

Acute haemorrhage from ruptured gastroesophageal varices is perhaps the most serious consequence of uncontrolled portal hypertension in cirrhotic patients. It represents a medical emergency and is associated with a high morbidity and mortality. In those who survive the initial bleeding event, the risks of further bleeding and other decompensated events remain high. The past 30 years have seen a slow evolution of management strategies that have greatly improved the chances of surviving a variceal haemorrhage. Liver cirrhosis is a multi-staged pathological process and we are moving away from a one-size-fits-all therapeutic approach. Instead there is an increasing recognition that a more nuanced approach will yield optimal survival for patients. This approach seeks to risk stratify patients according to their disease stage. The exact type and timing of treatment offered can then be varied to suit individual patients. At the same time, the toolbox of available therapy is expanding and there is a continual stream of emerging evidence to support the use of endoscopic and pharmacological therapies. In this review, we present a summary of the treatment options for a variety of different clinical scenarios and for when there is failure to control bleeding. We have conducted a detailed literature review and presented up-to-date evidence from either primary randomized-controlled trials or meta-analyses that support current treatment algorithms.

Emergency TIPS in a Child-Pugh B patient: When does the window of opportunity open and close?

Transjugular intrahepatic portosystemic shunt (TIPS) is used to treat complications of cirrhosis such as variceal bleeding and refractory ascites, but it also bears the risk of liver failure, overt hepatic encephalopathy (HE) and cardiac decompensation. Variceal bleeding may be controlled using endoscopic and medical treatment in patients with compensated cirrhosis; in decompensated patients, however, TIPS improves survival. Therefore, an early TIPS (within 72h or if later, still early after bleeding) might improve the survival of patients by preventing an inflammatory response and bacterial translocation. Both these processes mediate an impaired immunological and hemodynamic response, thereby facilitating the development of acute-on-chronic liver failure (ACLF) and/or death. Similarly, in patients with refractory ascites, TIPS should be used early in treatment to prevent acute kidney injury (AKI) and hepatorenal syndrome (HRS) after precipitating events induced by complications of portal hypertension. Whether TIPS and/or embolization should be used to treat portal vein thrombosis and spontaneous shunts is still a matter of debate and should be further investigated. In summary, the careful selection of patients for TIPS is crucial. New biomarkers, especially those evaluating systemic inflammation and bacterial translocation, might improve the predictive value of established clinical parameters such as bilirubin and overt HE. However, a significant amount of further research must be carried out.

Balloon-Occluded Retrograde Transvenous Obliteration (BRTO): A Novel Method of Control of Bleeding from Post-Glue Ulcer over Gastric Varices. Report of Two Cases and Review of Literature

Bleeding gastric varices (GV) are managed by cyanoacrylate glue injection with transjugular intrahepatic portosystemic shunt (TIPSS) as modality for treatment failure. Ulcer can form at the site of glue injection over GV and it can cause bleeding. Treatment approach for such bleed is not well described. Balloon-occluded retrograde transvenous obliteration (BRTO), TIPSS, and devascularization remain the treatment options in this scenario. BRTO is an endovascular procedure where a balloon catheter is inserted into a draining vein of GV, and the sclerosant can be injected into the varices through the catheter during balloon occlusion. BRTO has the benefit of increasing portal hepatic blood flow and can also be useful in patients who may not tolerate TIPSS. We report two cases where BRTO was done for control of bleeding from ulcers formed over previously injected GV.