Intermediate and long-term survival prediction using prognostic scores in patients undergoing salvage TIPS for uncontrolled variceal bleeding

JEJ Krige; EG Jonas; M Setshedi; SJ Beningfield; UK Kotze; MM Bernon; S Burmeister; JC Kloppers

Authors

JEJ Krige University of Cape Town https://orcid.org/0000-0002-7057-9156
EG Jonas University of Cape Town https://orcid.org/0000-0003-0123-256X
M Setshedi University of Cape Town https://orcid.org/0000-0002-7979-2981
SJ Beningfield University of Cape Town https://orcid.org/0000-0003-0727-2650
UK Kotze University of Cape Town https://orcid.org/0000-0003-1405-474X
MM Bernon University of Cape Town https://orcid.org/0000-0002-7967-8548
S Burmeister University of Cape Town https://orcid.org/0000-0003-0888-7606
JC Kloppers University of Cape Town https://orcid.org/0000-0003-2438-6879

Keywords:

portal hypertension, variceal bleeding, transjugular intrahepatic portosystemic shunt, salvage TIPS, rebleeding, survival

Abstract

Background: This study investigated the value of prognostic scores to predict 90-day, 1-, 3- and 5-year survival after salvage TIPS (sTIPS) in patients with exsanguinating variceal bleeding who failed endoscopic intervention.

Methods: The Model for End-Stage Liver Disease (MELD), Model for End-Stage Liver Disease Sodium (MELDNa), Acute Physiology and Chronic Health Evaluation II (APACHE II) and Child-Pugh (C-P) grades and scores were calculated using Kaplan-Meier curves and Cox proportional hazards models in sTIPS patients treated between August 1991 and November 2020.

Results: Thirty-four patients (29 men, 5 women), mean age 52 years, SD ± 11.6 underwent sTIPS which controlled bleeding in 32 (94%) patients. Ten (29.4%) patients died in hospital at a median of 4.8 (range 1–10) days. On bivariate analysis, C-P score ≥ 10 (p = 0.017), high C-P grade (p = 0.048), MELD ≥ 15 (p = 0.010), MELD-Na score ≥ 22 (p < 0.001) and APACHE II score ≥ 15 (p < 0.001) predicted 90-day mortality. Individual clinical characteristics associated with 90-day mortality were grade 3 ascites (p = 0.029), > 10 units of blood transfused (p = 0.004), balloon tube placement (p < 0.001), endotracheal intubation (< 0.001) and inotrope support (p < 0.001). The overall 90-day, 1-, 3- and 5-year survival rates were 67.6%, 55.9%, 26.5% and 20.6% respectively. Nine patients (26.5%) were alive at a median of two years (range 1–18 years) post-TIPS. Patients with C-P grade A, C-P score < 10, MELD score < 15, MELD-Na score < 22 and APACHE II score < 15 had significantly better 90-day, 1-, 3- and 5-year survival rates.

Conclusion: Although sTIPS controlled variceal bleeding in 94% of patients after failed endoscopic therapy, in-hospital mortality was 29% and less than one quarter were alive after five years. The selected cut-off values for the nominated scoring systems accurately predicted 90-day mortality and long-term survival.