Introduction: 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.
Materials and 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).
Conclusion: 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.
Departments of bAnaesthetics
cRadiology, Queen Elizabeth Hospital
dCentre for Liver Research and NIHR Liver Biomedical Research Unit, University of Birmingham, Birmingham, UK
Correspondence to Christopher Corbett, MBBS, Liver Unit, Queen Elizabeth Hospital, Birmingham B152TH, UK Tel: +44 121 415 8692; fax: +44 121 415 8701; e-mail: firstname.lastname@example.org
Received July 4, 2012
Accepted September 21, 2012