Cirrhotic patients with portal hypertension-related bleeding and an indication for early-TIPS: A large multicentre audit with real-life results

Autor: Dominique Thabut, Arnaud Pauwels, Nicolas Carbonell, Andre Jean Remy, Pierre Nahon, Xavier Causse, Jean-Paul Cervoni, Jean-François Cadranel, Isabelle Archambeaud, Slim Bramli, Florent Ehrhard, Philippe Ah-Soune, Florian Rostain, Alexandre Pariente, Julien Vergniol, Jean-Pierre Dupuychaffray, Anne-Laure Pelletier, Florence Skinazi, Anne Guillygomarc'h, René-Louis Vitte, Jean Henrion, Stéphanie Combet, Marika Rudler, Christophe Bureau, Roland Amathieu, Cécilia D'Arondel de Hayes, Karim Aziz, Hélène Barraud, Guy Bellaïche, Pierre-Olivier Bernard, Bruno Bour, Farah Zerouala Boussarah, Louis Buscail, Karine Chageanu-Derrode, Innocenti Dadamessi, Mathilde David, Thong Dao, François Dewaele, Nina Dib, Laurence Donato, Sylva Doumet, Marie Eccochard, Khaldoun Elriz, Stéphanie Faure, Anne-laure Gillet, Pascal Guivarch, Vincent Jouannaud, Laure Lamare, Yann Le Bricquir, Vincent Leroy, Véronique Lousteau-ratti, Alexandre Louvet, Gilles Macaigne, Stéphanie De Montigny, Eric Nguyen Khac, Violaine Ozenne, Jean-Louis Payen, Agnès Pélaquier, Jean-Marc Perarnau, Aurélie Plessier, Dr Joanna Pofelski, Ghassan Riachi, Jacques-Arnaud Seyrig, Faouzi Saliba, Philippe Sogni
Rok vydání: 2018
Předmět:
Zdroj: Journal of Hepatology. 68:73-81
ISSN: 0168-8278
DOI: 10.1016/j.jhep.2017.09.002
Popis: Background & Aims The Baveno VI consensus meeting concluded that an early transjugular intra-hepatic porto-systemic shunt (TIPS) must be considered in high-risk patients with cirrhosis, presenting with variceal bleeding (VB) (Child B + active bleeding at endoscopy or Child C10-13 patients). Whether this therapeutic approach is feasible in a real-life setting remains unclear. The aim of this study was to determine (i) the proportion of patients eligible for early-TIPS among patients with cirrhosis and VB, (ii) the proportion of these patients who underwent early-TIPS placement and the main reasons for discarding TIPS, and (iii) the outcomes of patients who experienced early-TIPS placement. Methods A large, national, prospective, multicentre audit of academic and non-academic centres, in which all French centres recruiting patients with gastrointestinal bleeding were invited to participate. All consecutive patients with cirrhosis and portal hypertension-related bleeding were included. Results A total of 964 patients were included (58 centres: 26 academic, 32 non-academic; patient characteristics: male sex 77%; age 59.6 ± 12.1 years; aetiologies of cirrhosis (alcoholic 67%, viral 15%, other 18%); source of bleeding (oesophageal varices 80%, gastric varices 11%, other 9%); active bleeding at endoscopy 34%; Child A 21%, B 44%, C 35%. Overall, 35% of the patients were eligible for early-TIPS, but only 6.8%, displaying less severe cirrhosis underwent early-TIPS placement. The main reason for discarding TIPS was a lack of availability. The actuarial probability of survival at one year was significantly increased in early-TIPS patients (85.7 ± 0.07% vs. 58.9 ± 0.03%, p = 0.04). The severity of liver disease was the only parameter independently associated with improved one-year survival. Conclusion In this real-life study, one-third of the patients with cirrhosis, admitted for VB fulfilled the criteria for early-TIPS placement, whereas only 7% had access to TIPS. TIPS was restricted to patients displaying less severe cirrhosis. The severity of liver disease was the only parameter that influenced survival. Lay summary Bleeding from oesophageal or gastric varices is a severe complication of cirrhosis, related to an increased pressure in the portal vein perfusing the liver. Some patients are described as “severe”, either because their liver disease is already severe, or because the bleeding is very important. Those patients could benefit from a prothesis, placed inside the liver by an interventional radiologist, aiming to decrease the pressure in the portal vein, just after the control of bleeding by medications and endoscopic treatment. New studies are warranted to demonstrate a real beneficial effect of this therapeutic attitude, which is not adopted in real-life practice, as shown by this national French audit of practice.
Databáze: OpenAIRE
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