Antegrade Transvenous Obliteration for Refractory Esophageal Variceal Hemorrhage in Patients Unsuitable for TIPS: A Multicenter Retrospective Study

Purpose: Esophageal variceal bleeding (EVB) refractory to endoscopic treatment in some patients with advanced cirrhosis, leaving few options other than transjugular intrahepatic portosystemic shunt (TIPS). However, patients with encephalopathy or heart failure are often ineligible for TIPS, alternatively opt for antegrade transvenous obliteration (ATO). This study aimed to assess the safety and efficacy of ATO compared to TIPS for refractory EVB.

Materials and Methods: This study retrospectively reviewed medical records from clinical data warehouse the Catholic University of Korea which encompass eight tertiary hospitals between 2012 and 2024. Although TIPS was initially considered, ATO was indicated for patients who were ineligible or failed for TIPS. ATO were implemented in 20 patients (age=62±10.2 years, men=13), while TIPS were created in 35 patients (age=58±12.6 years, men=26) for refractory EVB. The primary outcome was the difference in the 30-month overall survival (OS) rate between two groups, a noninferiority comparison to exclude a difference of >30 percentage point. The secondary outcomes were comparison of postprocedural adverse events and bleeding-free survival (BFS) between the ATO and TIPS groups.

Results: With median follow-up of 31 months, the BFS and OS rate at 30 months of ATO were 23.2% (95% confidence interval [CI], 7.8%, 69.7%) and 50.9% (95% CI, 32.0%, 81.0%), respectively; the corresponding rates of TIPS were 63.8% (95% CI, 45.4%, 89.7%) and 52.2% (95% CI, 34.1%, 79.8%). The absolute difference (TIPS minus ATO) in 30-month OS was 1.3 percentage points (95% CI, 33.7%, -31.1%). Within post-procedure one-week mortality or liver transplant occurred in five (14.3%) patients in TIPS, whereas there was no one-week morality in ATO group. Kaplan-Meier and log-rank test showed no significant differences between groups regarding BFS (p=0.07) and OS (p=0.41).

Conclusion: Although the outcomes fall short for the specified noninferiority, the ATO might be an alternative for those who are ineligible for TIPS in treatment of refractory EVB.