Covered TIPS vs endoscopic therapy + Β‐blocker for prevention of variceal rebleeding

Abstract Gastroesophageal variceal bleeding in cirrhotic patients is associated with significant morbidity and mortality, and a high rebleeding risk. Limited data are available on the role of TIPS with covered stents in patients receiving standard endoscopic, vasoactive and antibiotic treatment. In this multicenter randomized trial, long-term endoscopic variceal ligation (EVL) or glue injection + β-blocker treatment was compared with TIPS placement in 72 patients with a first or second episode of gastric and/or esophageal variceal bleeding, following hemodynamic stabilization upon endoscopic, vasoactive and antibiotic treatment. Randomization was stratified according to Child-Pugh score. Kaplan-Meier (event free) survival estimates were used for the endpoints rebleeding, death, treatment failure and hepatic encephalopathy. During a median follow-up of 23 months, 10 (29%) of 35 patients in the endoscopy + β-blocker group as compared with 0 of 37 (0%) patients in the TIPS group developed variceal rebleeding (p=0.001). Mortality (TIPS 32% vs. endoscopy 26%, p=0.418) and treatment failure (TIPS 38% vs. endoscopy 34%, p=0.685) did not differ between groups. Early hepatic encephalopathy (within 1-year) was significantly more frequent in the TIPS group (35% vs. 14%, p=0.035), but during long-term follow-up this difference diminished (38% vs. 23%, p=0.121). In unselected cirrhotic patients, who underwent successful endoscopic hemostasis for variceal bleeding, covered TIPS was superior to EVL + β-blocker for reduction of variceal rebleeding, but did not improve survival. TIPS was associated with higher rates of early hepatic encephalopathy. This article is protected by copyright. All rights reserved.