Preemptive TIPS reduces further decompensation and mortality in gastric variceal hemorrhage

Background: Gastric variceal hemorrhage (GVH) carries a 45% one-year mortality rate and even higher rebleeding risk than esophageal variceal bleeding (30-50% vs. 20-30%). Current guidelines recommend cyanoacrylate injection as first-line treatment, while TIPS is reserved for rescue therapy. However, unlike esophageal variceal bleeding, evidence supporting preemptive TIPS (pTIPS, within 72 hours) for preventing further decompensation and improving survival in GVH remains limited.

Aims: We investigated whether pTIPS could prevent further decompensation and improve survival compared to standard of care (SOC) in patients with GVH.

Method: This multicenter European study retrospectively evaluated cirrhotic patients with acute GVH. From a total cohort of 372 patients, 106 patients were analyzed after 1:1 propensity score matching (53 pTIPS, 53 SOC) based on key clinical parameters. Primary outcome was further decompensation (new or worsening ascites, rebleeding, hepatic encephalopathy （HE）, jaundice, spontaneous bacterial peritonitis, or hepatorenal syndrome-acute kidney injury). Secondary outcomes included mortality, rebleeding, and individual decompensation events over 12 months of follow-up.

Results: After matching, baseline characteristics were well-balanced with Child-Pugh and MELD score of 10 (8, 11) and 14(10, 19), respectively. Preemptive TIPS significantly reduced further decompensation compared to SOC (7.5% vs. 26.4%, p=0.01). In particular, rebleeding (1.9% vs. 22.6%, log-rank p=0.009) and ascites (1.9% vs. 9.4%, log-rank p=0.04) were significantly reduced in the pTIPS group. Moreover, pTIPS significantly reduced 12-month mortality (11.3% vs. 35.8%, log-rank p=0.004). In multivariate logistic regression, TIPS independently prevented further decompensation (OR 0.18, 95% CI 0.047-0.683, p=0.012). Cox regression confirmed TIPS as protective against mortality (HR 0.257, 95% CI 0.099-0.663, p=0.005), rebleeding (HR 0.06, 95% CI 0.008-0.473, p=0.008) and new or worsening of ascites (HR 0.077, 95% CI 0.008-0.709, p=0.024). Multivariate analysis showed no significant difference in HE risk between both groups (HR 1.023, 95% CI 0.474-2.209, p=0.954).

Conclusion: Preemptive TIPS for GVH significantly reduces the rate of further decompensation, in particular rebleeding and new or worsening ascites, which translates into significantly improved survival. The risk of HE was not increased by pTIPS. Our data support the use of pTIPS as first-line therapy for GVH.

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Artikel online veröffentlicht:
04. September 2025