Endovascular Interventions Reduce Rebleeding in Patients With Gastric Varices: An Individual Patient Data Meta-Analysis.

BACKGROUND & AIMS: There is no consensus on the optimal modality of secondary prophylaxis for gastric variceal (GV) bleeding in patients with cirrhosis.

METHODS

Observational studies and randomized controlled trials (RCTs) comparing endovascular interventions-balloon-occluded retrograde transvenous obliteration (BRTO) and transjugular intrahepatic portosystemic shunt (TIPS)-with endoscopic cyanoacrylate injection (ECI) were considered for the aggregate data meta-analysis. Individual patient data were collected from RCTs to perform an individual patient data meta-analysis in a propensity score-matched cohort. The primary outcome was comparison of the rates of all-cause rebleeding between ECI, BRTO, and TIPS. Secondary outcomes included overall survival, ascites, and hepatic encephalopathy.

RESULTS

Fifteen studies (11 observational and 4 RCTs) comprising 1240 patients (ECI: 377, BRTO: 575, and TIPS: 288) were included in the aggregate data meta-analysis. In the individual patient data meta-analysis, both BRTO (subdistribution hazard ratio [sHR], 0.15; 95% confidence interval [CI], 0.05-0.43; P = .004) and TIPS (sHR, 0.49; 95% CI, 0.27-0.89; P = .019) significantly reduced all-cause rebleeding compared with ECI, without survival benefit. BRTO was associated with a higher risk of new-onset or worsening of pre-existing ascites (sHR, 3.54; 95% CI, 1.31-9.55; P = .013); TIPS increased the risk of hepatic encephalopathy (sHR, 8.84; 95% CI, 2.0-39.11; P = .004) compared with ECI. Benefit in rebleeding reduction was most pronounced among patients with Child-Pugh class B cirrhosis. The analysis revealed limited long-term outcome data, inconsistencies in reported trial outcomes, and significant heterogeneity in results, particularly regarding TIPS.

CONCLUSIONS

Endovascular interventions (BRTO and TIPS) are superior to ECI for reducing all-cause rebleeding in patients with cirrhosis and gastric variceal hemorrhage. Larger studies with standardized end points and long-term outcomes are needed to clarify survival benefit and optimize treatment selection.