Portosystemic shunt for variceal esophagogastric bleeding and risk of early re-bleeding. Rationale for involuntary intervention: A single-center observational controlled study

Background. Variceal esophageal-gastric bleeding is considered to be a life-threatening complication of portal hypertension in patients with cirrhosis. In some cases, only portosystemic shunt can serve as a life-saving intervention for the patient.

Aim. To justify the forced expediency of transjugular intrahepatic portosystemic shunt (TIPS) in case of ineffective drug and endoscopic hemostasis or a high risk of early recurrence of variceal bleeding.

Methods. A single-center observational controlled study was conducted to analyze the results of shunt procedure in 62 patients during the period of 2017–2023. The patients were divided into 2 groups: the main group (n = 32) with patients who underwent “early” shunt procedure in a “salvage” variant (n = 10) with continued bleeding and in a “pre-emptive” variant (n = 22) with a high risk of early recurrence of hemorrhage, and the control group (n = 30) with patients who underwent planned shunt procedure. The value of the portosystemic pressure gradient was calculated by subtracting the value of the pressure in the inferior vena cava recorded at the initial stage of the operation from the value of the initial pressure in the portal vein, measured by direct manometry. The authors compared the dynamics of the portosystemic pressure gradient in the study groups at similar stages of the intervention — initial, after embolization of the veins of portal blood flow to the varix, after shunt stenting. The study involved the analysis of mortality rates (6-week, one-year, for the entire observation period) and complications. Statistica-for-Windows 12.0 (StatSoft®, USA) and Excel (Microsoft, USA) were used to calculate descriptive statistics.

Results. Patients of both groups achieved normalization of pressure in the portal vein system and, accordingly, the portosystemic pressure gradient as a result of shunt surgery. Effective portal decompression was confirmed by their significant reduction. In the portal vein, the pressure decreased from 33.84 ± 2.70 to 20.53 ± 1.27 mmHg (t = 4.46; p < 0.001) in the main group and from 32.80 ± 3.07 to 20.10 ± 1.60 mmHg (t = 3.67; p < 0.001) in the control group. The dynamics of the portosystemic pressure gradient showed a significant decrease from 26.16 ± 2.69 to 10.06 ± 0.88 mm Hg (t = 5.69; p < 0.001) in the main group, and from 24.83 ± 2.73 to 9.67 ± 1.21 mm Hg (t = 5.08; p < 0.001) in the control group. Together with embolization of the vessels of the hepatofugal inflow of portal blood to the varices, this led to a stable and long-term cessation of variceal bleeding. When comparing the results of shunt procedure in the study groups, no significant differences were found in terms of differentiated mortality rates and complications in both the early and long-term periods. In the main group, the 6-week and one-year mortality rates accounted for 6.3% (n = 2) and 15.6% (n = 5), in the control group — 6.7% (n = 2) and 13.3% (n = 4), respectively (p = 0.917). Mortality in the main group comprised 25.0% (n = 8) over 58 months, in the control group — 23.3% (n = 7) over 60 months (p = 0.886).

Conclusion. The transjugular shunt provides a significant reduction in the portosystemic pressure gradient. “Salvage” and “pre-emptive” shunt options can prevent death and early recurrence of bleeding. Their effectiveness increases due to endovascular blockage of vessels that ensures the overflow of esophagogastric varices with portal blood.

1. Ivashkin VT, Maevskaya MV, Zharkova MS, Zhigalova SB, Kitsenko EA, Manukyan GV, Trukhmanov A.S., Maev I.V., Tikhonov I.N., Deeva T.A. Clinical Recommendations of the Russian Scientific Liver Society and Russian Gastroenterological Association on Diagnosis and Treatment of Liver Fibrosis, Cirrhosis and Their Complications. Russian Journal of Gastroenterology, Hepatology, Coloproctology. 2021;31(6):56–102 (In Russ.). https://doi.org/10.22416/1382-4376-2021-31-6-56-102

2. de Franchis R, Bosch J, Garcia-Tsao G, Reiberger T, Ripoll C; Baveno VII Faculty. Baveno VII — Renewing consensus in portal hypertension. J Hepatol. 2022;76(4):959–974. https://doi.org/10.1016/j.jhep.2021.12.022

3. Lv Y, Liu N, Li Y, Wu J, Zheng J, Li X, Zeng M. Coagulation Dysfunction in Patients with Liver Cirrhosis and Splenomegaly and Its Countermeasures: A Retrospective Study of 1522 Patients. Dis Markers. 2023;2023:5560560. https://doi.org/10.1155/2023/5560560

4. Lisman T. Bleeding and Thrombosis in Patients With Cirrhosis: What’s New? Hemasphere. 2023;7(6):e886. https://doi.org/10.1097/HS9.0000000000000886

5. Korobka VL, Pasetchnikov VD, Korobka RV, Pak ES, Shapovalov AM. Use of endoscopic band ligation alone and in combination with nonselective beta blockers for prevention of variceal bleeding in ascites patients on the liver transplant waiting list. Russian Journal of Transplantology and Artificial Organs. 2022;24(3):42–50 (In Russ.). https://doi.org/10.15825/1995-1191-2022-3-42-50

6. Garcia-Tsao G, Abraldes JG, Berzigotti A, Bosch J. Portal hypertensive bleeding in cirrhosis: Risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the study of liver diseases. Hepatology. 2017;65(1):310–335. https://doi.org/10.1002/hep.28906

7. Diaz-Soto MP, Garcia-Tsao G. Management of varices and variceal hemorrhage in liver cirrhosis: a recent update. Therap Adv Gastroenterol. 2022;15:17562848221101712. https://10.1177/17562848221101712

8. Sun L, Long L, Wang Q, Xiang H; Members of the Expert Consensus Steering Committee (in alphabetical order). Expert consensus on emergency procedures for portal hypertension bleeding (2022). J Interv Med. 2023;6(1):1–9. https://doi.org/10.1016/j.jimed.2022.10.006

9. Bouzbib C, Sultanik P, Thabut D, Rudler M. Unsolved Questions in Salvage TIPSS: Practical Modalities for Placement, Alternative Therapeutics, and Long-Term Outcomes. Can J Gastroenterol Hepatol. 2019;2019:7956717. https://doi.org/10.1155/2019/7956717

10. Weichselbaum L, Lepida A, Marot A, Trépo E, Moreno C, Deltenre P. Salvage transjugular intrahepatic portosystemic shunt in patients with cirrhosis and refractory variceal bleeding: A systematic review with meta-analysis. United European Gastroenterol J. 2022;10(8):874–887. https://doi.org/10.1002/ueg2.12300

11. Hernández-Gea V, Procopet B, Giráldez Á, Amitrano L, Villanueva C, Thabut D, Ibañez-Samaniego L, Silva-Junior G, Martinez J, Genescà J, Bureau C, Trebicka J, Llop E, Laleman W, Palazon JM, Castellote J, Rodrigues S, Gluud LL, Noronha Ferreira C, Barcelo R, Cañete N, Rodríguez M, Ferlitsch A, Mundi JL, Gronbaek H, Hernández-Guerra M, Sassatelli R, Dell’Era A, Senzolo M, Abraldes JG, Romero-Gómez M, Zipprich A, Casas M, Masnou H, Primignani M, Krag A, Nevens F, Calleja JL, Jansen C, Robic MA, Conejo I, Catalina MV, Albillos A, Rudler M, Alvarado E, Guardascione MA, Tantau M, Bosch J, Torres F, Garcia-Pagán JC; International Variceal Bleeding Observational Study Group and Baveno Cooperation. Preemptive-TIPS Improves Outcome in High-Risk Variceal Bleeding: An Observational Study. Hepatology. 2019;69(1):282–293. https://doi.org/10.1002/hep.30182

12. Manning C, Elzubeir A, Alam S. The role of pre-emptive Transjugular Intrahepatic Portosystemic Shunt in acute variceal bleeding: a literature review. Ther Adv Chronic Dis. 2021;12:2040622321995771. https://doi.org/10.1177/2040622321995771

13. Boike JR, Thornburg BG, Asrani SK, Fallon MB, Fortune BE, Izzy MJ, Verna EC, Abraldes JG, Allegretti AS, Bajaj JS, Biggins SW, Darcy MD, Farr MA, Farsad K, Garcia-Tsao G, Hall SA, Jadlowiec CC, Krowka MJ, Laberge J, Lee EW, Mulligan DC, Nadim MK, Northup PG, Salem R, Shatzel JJ, Shaw CJ, Simonetto DA, Susman J, Kolli KP, Van-Wagner LB; Advancing Liver Therapeutic Approaches (ALTA) Consortium. North American Practice-Based Recommendations for Transjugular Intrahepatic Portosystemic Shunts in Portal Hypertension. Clin Gastroenterol Hepatol. 2022;20(8):1636–1662.e36. https://doi.org/10.1016/j.cgh.2021.07.018

14. Nicoară-Farcău O, Han G, Rudler M, Angrisani D, Monescillo A, Torres F, Casanovas G, Bosch J, Lv Y, Thabut D, Fan D, Hernández-Gea V, García-Pagán JC; Preemptive TIPS Individual Data Metanalysis, International Variceal Bleeding Study and Baveno Cooperation Study groups. Effects of Early Placement of Transjugular Portosystemic Shunts in Patients With High-Risk Acute Variceal Bleeding: a Meta-analysis of Individual Patient Data. Gastroenterology. 2021;160(1):193–205.e10. https://doi.org/10.1053/j.gastro.2020.09.026

15. Ishikawa T. Efficacy of interventional radiology in the management of portal hypertension: A narrative review. Medicine (Baltimore). 2022;101(33):e30018. https://doi.org/10.1097/MD.0000000000030018

16. Posa A, Tenore L, Barbieri P, Mazza G, Sala E, Iezzi R. The Role of the Transjugular Intrahepatic Porto-Systemic Shunt in an Emergency Setting. Life (Basel). 2023 Mar 24;13(4):868. https://doi.org/10.3390/life13040868

17. Wang L, Song QK, Yue ZD, Zhao HW, Fan ZH, Wu YF, Liu FQ, Meng K, Zhang L, Jiang HG, Ding YN, Zhang Y. [Study on the correlation between PPG and HVPG in patients with portal hypertension]. Zhonghua Gan Zang Bing Za Zhi. 2022;30(7):722–727. Chinese. https://doi.org/10.3760/cma.j.cn501113-20200603-00291

18. Luo SH, Zhou MM, Cai MJ, Han SL, Zhang XQ, Chu JG. Reduction of portosystemic gradient during transjugular intrahepatic portosystemic shunt achieves good outcome and reduces complications. World J Gastroenterol. 2023;29(15):2336–2348. https://doi.org/10.3748/wjg.v29.i15.2336

19. Luo X, Wang X, Li X. Variceal embolisation plus TIPS for variceal bleeding. Lancet Gastroenterol Hepatol. 2022;7(9):789. https://doi.org/10.1016/S2468-1253(22)00202-3

20. Jaber F, Beran A, Alsakarneh S, Ahmed K, Abdallah M, Elfert K, Almeqdadi M, Jaber M, Mohamed WT, Ahmed M, Al Momani L, Numan L, Bierman T, Helzberg JH, Ghoz H, Clarkston WK. Transjugular Intrahepatic Portosystemic Shunt With or Without Gastroesophageal Variceal Embolization for the Prevention of Variceal Rebleeding: A Systematic Review and Meta-Analysis. Gastroenterology Res. 2023;16(2):68–78. https://doi.org/10.14740/gr1618

21. Xu G, Li F, Mao Y. Portal pressure monitoring-state-of-the-art and future perspective. Ann Transl Med. 2019;7(20):583. https://doi.org/10.21037/atm.2019.09.22

22. Zhang D, Wang T, Yue ZD, Wang L, Fan ZH, Wu YF, Liu FQ. Hepatic venous pressure gradient: Inaccurately estimates portal venous pressure gradient in alcoholic cirrhosis and portal hypertension. World J Gastrointest Surg. 2023;15(11):2490–2499. https://doi.org/10.4240/wjgs.v15.i11.2490

23. Mazumder NR, Jezek F, Tapper EB, Beard DA. Portal Venous Remodeling Determines the Pattern of Cirrhosis Decompensation: A Systems Analysis. Clin Transl Gastroenterol. 2023;14(9):e00590. https://doi.org/10.14309/ctg.0000000000000590

24. Lopera JE. A Comprehensive Review of Transjugular Intrahepatic Portosystemic Shunt-Related Complications. Semin Intervent Radiol. 2023;40(1):55–72. https://doi.org/10.1055/s-0043-1767670

25. Wang HY, Song QK, Yue ZD, Wang L, Fan ZH, Wu YF, Dong CB, Zhang Y, Meng MM, Zhang K, Jiang L, Ding HG, Zhang YN, Yang YP, Liu FQ. Correlation of pressure gradient in three hepatic veins with portal pressure gradient. World J Clin Cases. 2022;10(14):4460–4469. https://doi.org/10.12998/wjcc.v10.i14.4460

26. Kiani C, Zori AG. Recent advances in pathophysiology, diagnosis and management of hepatorenal syndrome: A review. World J Hepatol. 2023;15(6):741–754. https://doi.org/10.4254/wjh.v15.i6.741

27. Yao Y, Satapathy SK, Fernandes ESM, Ramírez-Fernández O, Vitale A, Chen Z. Hepatic venous pressure gradient (HVPG) predicts liver failure after transjugular intrahepatic portal shunt: a retrospective cohort study. Ann Transl Med. 2022;10(20):1122. https://doi.org/10.21037/atm-22-4737

28. Saltini D, Indulti F, Guasconi T, Bianchini M, Cuffari B, Caporali C, Casari F, Prampolini F, Senzolo M, Colecchia A, Schepis F. Transjugular Intrahepatic Portosystemic Shunt: Devices Evolution, Technical Tips and Future Perspectives. J Clin Med. 2023;12(21):6758. https://doi.org/10.3390/jcm12216758