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