Balloon tamponade sequentially combined with TIPS for refractory acute variceal bleeding: efficacy, safety and procedural techniques

This study aimed to evaluate the efficacy and safety of a therapeutic strategy, balloon tamponade (BT) sequentially combined with transjugular intrahepatic portosystemic shunt (TIPS), in cirrhotic patients with refractory acute variceal bleeding (AVB), and to introduce technical points of performing TIPS under BT. Consecutive patients with refractory AVB treated with this strategy from February 2017 to December 2019 were retrospectively analyzed. We evaluated the technical success rate, efficacy of TIPS treatment, procedure-related complications and dynamic change of liver function. Variceal rebleeding, shunt patency, overt hepatic encephalopathy (OHE) and survival were assessed during follow-up. Sixteen patients were included in the study. TIPS procedure was successfully performed in all patients, and balloon was deflated during TIPS in eight patients, after TIPS in three and before TIPS in five. Mean portal pressure gradient (PPG) decreased from 28.3 ± 4.2 to 11.0 ± 2.9 mmHg, and a reduction > 50% was achieved in all patients. No TIPS- and balloon-related complications were observed. During a median follow-up of 16.7 (IQR 12.1–26.5) months, two patients experienced rebleeding, two patients developed shunt dysfunction, and OHE occurred in three patients. Two patients died during follow-up, with a cumulative survival rate of 100% at 6 weeks and 81% at 1 year. Balloon tamponade sequentially combined with TIPS should be considered an effective and safe strategy for patients with refractory AVB. This strategy was associated with lower incidence of TIPS- and balloon-related complications and recurrent variceal bleeding.