Left gastric vein embolization during TIPS placement for acute variceal bleeding has no effect on bleeding recurrence: Results of a multicenter study - 01/02/23

Doi : 10.1016/j.diii.2023.01.005

Paul Calame ^a,^b,^⁎, Mathieu Rostam ^c, Louis d'Alteroche ^d, Alexandre Malakhia ^a,^e, Jean-Paul Cervoni ^f, Delphine Weil ^f, Vincent Di Martino ^f, Olivier Sutter ^g, Michel Greget ^h, Jean-Romain Risson ⁱ, Mathilde Vionnet ^j, Antoine Bouvier ^k, Fatima-Zohra Mokrane ^l, Julien Ghelfi ^m, Panteleimon Papadopoulos ⁿ, Christian Sangel ^m, Agnes Rodes ^o, Jean Goupil ^p, Eric Delabrousse ^a,^b, Frederic Douane ^c, Romaric Loffroy ^e
LVGE-TIPS Group^q
Olivier Chevallier ^q, Thomas Hebert ^q, Antoine Boizet ^q, Ayoub Guerrab ^q, Nicolas Raynaud ^q, Pierre-Quentin Carbillet ^q, Victor Dumas ^q, Stéphane Velasco ^q, Bruno Lapuyade ^q, Marie-Annaig Pey ^q, Emanuele Boatta ^q, Pierre De Marini ^q, Jules Cœur ^q, Pierre Verdot ^q
^q Club Francophone pour l’Étude de l'Hypertension Portale (CFEHTP)

^a Department of Radiology, University of Bourgogne Franche-Comté, CHRU Besançon, 25030, Besançon, France
^b EA 4662 Nanomedicine Lab, Imagery and Therapeutics, University of Franche-Comté, 25030, Besançon, France
^c Department of Radiology, CHU de Nantes, 44000, Nantes, France
^d Department of Hepatology, CHU Trousseau, 37550, Tours, France
^e Department of Radiology, CHU Dijon-Bourgogne, 21079, Dijon, France
^f Department of Hepatology, University of Bourgogne Franche-Comté, CHRU Besançon, 25030, Besançon, France
^g Interventional Radiology Unit, Avicenne Hospital, Paris-Seine-Saint-Denis University Hospitals, Assistance-Publique Hopitaux de Paris, 93000, Bobigny, France
^h Department of Radiology, Strasbourg University Hospital, 67200, Strasbourg, France
ⁱ Department of Radiology, CHU Brest, 29609, Brest, France
^j Department of Radiology, CHU de Poitiers, 86000, Poitiers, France
^k Department of Radiology, University Hospital, 49100, Angers, France
^l Department of Radiology, University of Toulouse III Paul Sabatier, 31062, Toulouse, France
^m Department of Radiology, University of Grenoble-Alpes, 38700, Grenoble, France
ⁿ Department of Radiology, CHU de Bordeaux, 33400, Bordeaux, France
^o Department of Radiology, Hôpital de la Croix Rousse, Centre Hospitalier Universitaire de Lyon, 69004, Lyon, France
^p Department of Radiology, CHU de Nîmes, 30900, Nîmes, France

^⁎Corresponding author: p1calame@chu-besancon.fr

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Highlights

•	In a multicenter retrospective study of 356 patients who underwent transjugular intrahepatic portosystemic shunt (TIPS) placement for acute variceal bleeding, 21 (6%) patients experienced bleeding recurrence at six weeks.
•	At six weeks, rebleeding-free survival does not differ significantly between patients who underwent left gastric vein embolization during TIPS placement (6/128; 5%) and those who did not (15/228; 7%) (P = 0.622).
•	Multivariable analysis identifies persisting portal pressure gradient after transjugular intrahepatic portosystemic shunt placement as the single independent variable associated with bleeding recurrence.

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Abstract

Purpose

The purpose of this study was to evaluate whether concomitant left gastric vein embolization (LGVE) during transjugular intrahepatic portosystemic shunt (TIPS) for acute variceal hemorrhage could reduce the risk of bleeding recurrence.

Material and method

A national multicenter observational study was conducted in 14 centers between January 2019 and December 2020. All cirrhotic patients who underwent TIPS placement for acute variceal bleeding were included. During TIPS procedure, size of left gastric vein (LGV), performance of LGVE, material used for LGVE and portosystemic pressure gradient (PPG) before and after TIPS placement were collected. A propensity score for the occurrence of LGVE was calculated to assess effect of LGVE on rebleeding recurrence at six weeks and one year.

Results

A total of 356 patients were included (mean age 57.3 ± 10.8 [standard deviation] years; 283/356 [79%] men). Median follow-up was 11.2 months [interquartile range: 1.2, 13.3]. The main indication for TIPS was pre-emptive TIPS (162/356; 46%), rebleeding despite secondary prophylaxis (105/356; 29%), and salvage TIPS (89/356; 25%). Overall, 128/356 (36%) patients underwent LGVE during TIPS procedure. At six weeks and one year, rebleeding-free survival did not differ significantly between patients who underwent LGVE and those who did not (6/128 [5%] vs. 15/228 [7%] at six weeks, and 11/128 [5%] vs. 22/228 [7%] at one year, P = 0.622 and P = 0.889 respectively). A total of 55 pairs of patients were retained after propensity score matching. In patients without LGVE, the rebleeding rate was not different from those with LGVE (3/55 [5%] vs. 4/55 [7%], P > 0.99, and 5/55 [9%] vs. 6/55[11%], P > 0.99, at six weeks and one year respectively). Multivariable analysis identified PPG after TIPS placement as the only predictor of bleeding recurrence (hazard ratio = 1.09; 95% confidence interval: 1.02–1.18; P = 0.012).

Conclusion

In this multicenter national real-life study, we did not observe any benefit of concomitant LGVE during TIPS placement for acute variceal bleeding on bleeding recurrence rate.

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Keywords : Esophageal and gastric varices, Gastrointestinal hemorrhage, Portal pressure, Portosystemic shunt, Propensity score, Transjugular intrahepatic portosystemic shunt

Abbreviations : AUC, CI, CT, HR, HBV, HCV, HVPG, IQR, LGV, LGVE, NASH, PPG, SD, SMD, TIPS