Self-expanding metal stent for refractory variceal bleeding: an umbrella review with the synthesis of the best evidence

Aims Acute variceal bleeding is one of the most common life-threatening complications in patients with cirrhosis, with an overall mortality of 20%. Despite conventional measures failure to control variceal bleeding occurs in up to 13% of cases. These cases are best managed by salvage trans-jugular intra-hepatic portosystemic shunt (TIPS). However, TIPS in an emergency setting is associated with high mortality. Self-expanding metal stents (SEMS) implantation is emerging as an attractive alternative over more established methods such as balloon tamponade (BT). We aimed to conduct an umbrella review by collecting and assessing multiple systematic reviews and meta-analyses on SEMS implantation.

Methods The protocol was registered in PROSPERO (registration Number CRD42023417621). A comprehensive search of electronic databases MEDLINE (via PubMed), EMBASE, SCOPUS, and Cochrane Library was conducted for studies published between the beginning of each database and September 2024. We included any systematic reviews that assessed the use of SEMs in cirrhotic adult patients who present with uncontrolled acute variceal bleeding in terms of treatment efficacy, technical success rate, complication rate and type of complication (rebleeding, ulceration, or stent migration), all-cause mortality. The risk of bias was assessed with the ROBIS tool.

Results Out of 1636 articles screened, we identified five systematic reviews of uncontrolled acute variceal bleeding treated with SEMS. The risk of bias was assessed as overall low. Technical success for SEMS deployment was achieved in 97% (95% CI 91%-100%). The most common complication was stent migration 0.28 (95% CI 0.17-0.43). One study compared SEMs vs BT which found that failure to control bleeding with balloon rate was 12.7% and 35.5% respectively but mid-term mortality was comparable. One study compared SEMS vs TIPS which found that failure to control bleeding rate was 15.5% vs 2.1% respectively and mid-term mortality was 43.6% and 27.9% respectively. Three studies reported on SEMS only and the results were consistent with comparative studies.

Conclusions Self-expanding metal stent implantation represents a valid alternative to balloon tamponade with a higher rate of early variceal bleeding control but comparable mid-term mortality. However, TIPS remains the most effective strategy, with the highest success rate and the best mid-term mortality. Further randomised studies are needed to confirm these findings.

Publication History

Article published online:
27 March 2025