174 - Impact of Pre-Emptive TIPS on Outcomes in Acute-on-Chronic Liver Failure with Variceal Bleeding

Purpose: Pre-emptive transjugular intrahepatic portosystemic shunt (pTIPS), defined as placement within 72 hours of initial endoscopic therapy for an active variceal bleed, has been proposed as a strategy to reduce rebleeding and improve survival in high-risk patients with cirrhosis. We evaluated outcomes of patients with acute-on-chronic liver failure (ACLF) who presented with variceal bleeding and underwent therapeutic endoscopy (EGD) with or without the addition of pre-emptive TIPS.

Materials and Methods: The Nationwide Readmissions Database (2010–2022) was queried for ACLF patients, using previously validated algorithms{1}, admitted with variceal upper GI bleeding who received EGD. Patients were stratified into EGD+pTIPS vs. therapeutic EGD alone. Primary outcomes were 30- and 90-day unplanned and GI bleed-related readmissions; secondary outcomes included blood transfusion (BT)-related readmissions. Multivariable hierarchical regression adjusted for demographics and comorbidities was performed.

Results: 142,969 patients were identified, of whom 6,963 (4.6%) underwent pTIPS+EGD. Predictors of pTIPS utilization are shown in Table 1. pTIPS was associated with higher odds of unplanned readmission at 30 days (OR: 1.29; p< 0.001) and similar odds at 90 days (OR: 1.09; p=0.13). pTIPS had significantly lower odds of GIB-related readmission at 30 days (OR: 0.55; p< 0.001) and 90 days (OR: 0.46; p< 0.001). Secondary analyses showed reduced BT-related readmissions at 90 days (OR: 0.71; p< 0.001) and similar odds at 30 days (OR: 0.88; p=0.29).

Conclusion: In patients with ACLF presenting with variceal bleeding, therapeutic EGD combined with pTIPS was associated with fewer GI bleed-related readmissions and lower transfusion requirements, but at the cost of higher 30-day unplanned readmission. These findings highlight the importance of early GI–IR collaboration in selecting patients with ACLF who may derive the greatest benefit from the addition of pTIPS. Incorporating additional clinical variables such as hepatic encephalopathy will be essential to refine selection criteria and optimize outcomes.