Gastroenterol Res

Gastroenterology Research, ISSN 1918-2805 print, 1918-2813 online, Open Access

Article copyright, the authors; Journal compilation copyright, Gastroenterol Res and Elmer Press Inc

Journal website https://www.gastrores.org

Original Article

Volume 16, Number 2, April 2023, pages 68-78

Transjugular Intrahepatic Portosystemic Shunt With or Without Gastroesophageal Variceal Embolization for the Prevention of Variceal Rebleeding: A Systematic Review and Meta-Analysis

Figure 1. PRISMA flowchart for the selection process. PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Figure 2. Forest plots of meta-analyses comparing the incidence of variceal rebleeding between the TIPS alone groups and TIPS combined with variceal embolization group (TIPS + EMB). TIPS: transjugular intrahepatic portosystemic shunt; EMB: embolization; CI: confidence interval.

Figure 3. Forest plots of meta-analyses comparing the incidence of variceal rebleeding between the TIPS alone groups and TIPS combined with variceal embolization group (TIPS + EMB) based on stent types (covered vs. bare vs. combined vs. unknown). TIPS: transjugular intrahepatic portosystemic shunt; EMB: embolization; CI: confidence interval.

Figure 4. Forest plots of meta-analyses comparing the incidence of (a) encephalopathy, (b) shunt dysfunction, and (c) mortality between the TIPS alone groups and TIPS combined with variceal embolization group (TIPS + EMB). TIPS: transjugular intrahepatic portosystemic shunt; EMB: embolization; CI: confidence interval.

**Table 1.** Baseline Characteristics of the Included Studies
Study, year	Country	Study period	Study design	No. of patients included in analysis	Mean age (SD)	Male/female	Study population
SD: standard deviation; GOV: gastroesophageal varices; IGV: isolated gastric varices; EGVB: esophagogastric variceal bleeding; NA: not available.
Lv et al, 2022 [17]	China	2014 - 2016	RCT	134	49.9 (11.6)	99/35	18 - 75 years with cirrhosis and had variceal bleeding in the past 6 weeks despite endoscopic treatment plus non-selective β-blockers for secondary prophylaxis
Yu et al, 2019 [14]	China	2011 - 2015	Retrospective, single study	82	53.9 (11.7)	54/28	Bleeding from cardiofundal varices, historical evidence of hemorrhage from the varices refractory to medical or endoscopic therapy; the presence of GOV-2 or IGV-1
Zheng et al, 2016 [21]	China	2010 - 2015	Retrospective, single study	70	56.3 (11.3)	52/18	Acute EGVB is ineffective after drug or endoscopic treatment, or multiple recurrences after bleeding is temporarily controlled
Lakhoo et al, 2016 [15]	USA	1999 - 2014	Retrospective, single study	26	54, median	16/10	Gastric varix hemorrhage refractory to medical therapy
Shi et al, 2014 [16]	China	2006-2011	Retrospective, single study	101	50.4 (10)	53/48	Esophageal variceal bleeding refractory to endoscopic therapy
Chen et al, 2013 [10]	China	2007 - 2011	RCT	106	52.4 (12.6)	66/40	Recurrent gastroesophageal variceal bleeding who had undergone failed endoscopic and medical therapy
Xiao et al, 2011 [9]	China	2002 - 2008	Retrospective, single study	79	44.3 (8.5)	59/20	Historical evidence of repeated bleeding or episode of massive bleeding
Xue et al, 2011 [13]	China	2002 - 2009	Retrospective, single study	67	51 (12.83), median	52/28	Esophageal variceal bleeding refractory to endoscopic therapy
Gaba et al, 2010 [12]	USA	2003 - 2008	Retrospective, single study	52	52, median	29/23	Acute (within 24 h) or recent (more than 24 h prior) hemorrhage from GOV refractory to endoscopic therapy
Wu et al, 2009 [22]	China	1993 - 2008	Retrospective, single study	263	NA	NA	Portal hypertension with variceal bleeding
Tesdal et al, 2006 [11]	Germany	1991 - 2002	Prospective, single study	95	55.9 (11.3)	61/34	Severe bleeding that had failed to respond to endoscopic sclerotherapy of esophageal varices or had gastric varices not amenable to sclerotherapy

Table 1. Baseline Characteristics of the Included Studies

Study, year

Country

Study period

Study design

No. of patients included in analysis

Mean age (SD)

Male/female

Study population

SD: standard deviation; GOV: gastroesophageal varices; IGV: isolated gastric varices; EGVB: esophagogastric variceal bleeding; NA: not available.

Lv et al, 2022 [17]

China

2014 - 2016

RCT

134

49.9 (11.6)

99/35

18 - 75 years with cirrhosis and had variceal bleeding in the past 6 weeks despite endoscopic treatment plus non-selective β-blockers for secondary prophylaxis

Yu et al, 2019 [14]

China

2011 - 2015

Retrospective, single study

53.9 (11.7)

54/28

Bleeding from cardiofundal varices, historical evidence of hemorrhage from the varices refractory to medical or endoscopic therapy; the presence of GOV-2 or IGV-1

Zheng et al, 2016 [21]

China

2010 - 2015

Retrospective, single study

56.3 (11.3)

52/18

Acute EGVB is ineffective after drug or endoscopic treatment, or multiple recurrences after bleeding is temporarily controlled

Lakhoo et al, 2016 [15]

USA

1999 - 2014

Retrospective, single study

54, median

16/10

Gastric varix hemorrhage refractory to medical therapy

Shi et al, 2014 [16]

China

2006-2011

Retrospective, single study

101

50.4 (10)

53/48

Esophageal variceal bleeding refractory to endoscopic therapy

Chen et al, 2013 [10]

China

2007 - 2011

RCT

106

52.4 (12.6)

66/40

Recurrent gastroesophageal variceal bleeding who had undergone failed endoscopic and medical therapy

Xiao et al, 2011 [9]

China

2002 - 2008

Retrospective, single study

44.3 (8.5)

59/20

Historical evidence of repeated bleeding or episode of massive bleeding

Xue et al, 2011 [13]

China

2002 - 2009

Retrospective, single study

51 (12.83), median

52/28

Esophageal variceal bleeding refractory to endoscopic therapy

Gaba et al, 2010 [12]

USA

2003 - 2008

Retrospective, single study

52, median

29/23

Acute (within 24 h) or recent (more than 24 h prior) hemorrhage from GOV refractory to endoscopic therapy

Wu et al, 2009 [22]

China

1993 - 2008

Retrospective, single study

263

Portal hypertension with variceal bleeding

Tesdal et al, 2006 [11]

Germany

1991 - 2002

Prospective, single study

55.9 (11.3)

61/34

Severe bleeding that had failed to respond to endoscopic sclerotherapy of esophageal varices or had gastric varices not amenable to sclerotherapy

**Table 2.** Baseline Patients Characteristics of the Included Studies
Study, year	No. of patients	TIPS alone (n)	TIPS + embolization (n)	Child score in TIPS alone (A/B/C)	Child score in TIPS + embolization (A/B/C)	Varices location	Stent type	Embolic agents	Time of embolization in relation to TIPS
^aInclude both groups. GEV: gastroesophageal varices; TIPS: transjugular intrahepatic portosystemic shunt; IGV: isolated gastric varices; NA: not available.
Lv et al, 2022 [17]	134	65	69	31/26/8	38/27/4	Esophagus: 21/GEV1: 33/GEV2: 11	Esophagus: 23 /GEV1: 34/GEV2: 12	Covered	Coils	After TIPS
Yu et al, 2019 [14]	82	27	55	14/11/2	21/24/10	GEV2: 22/IGV1: 5	GEV2: 34/IGV1: 21	Covered	Combined (coils, vascular plug, sclerosing agent)	After TIPS
Zheng et al, 2016 [21]	70	15	55	NA	NA	Esophageal and gastric fundus varices	Combined (covered and bare)	Combined (coils, sclerosing agent)	After TIPS
Lakhoo et al, 2016 [15]	26	8	18	NA	NA		Covered	Combined (coils, vascular plug)	After TIPS
Shi et al, 2014 [16]	101	48	53	11/28/9	16/29/8	Esophageal and gastric fundus varices	Covered	Sclerosing agents	Before TIPS
Chen et al, 2013 [10]	106	52	54	9/40/3	12/37/5	NA	Covered	Coils	Before TIPS
Xiao et al, 2011 [9]	79	36	43	14/18/4	15/20/8	Esophageal: 23/fundus: 13	Esophageal: 25/fundus: 18	Bare	Combined (coils, α-cyanoacrylate)	After TIPS
Xue et al, 2011 [13]	67	40	27	37/22/21^a	Esophageal: 29/fundus: 11	Esophageal: 10/fundus: 17	Combined (covered and bare)	Coils or ethanol	unspecified
Gaba et al, 2010 [12]	52	37	15	6/28/18^a	Esophageal: 24/gastric: 13	Esophageal: 7/gastric: 8	Covered	Coils	After TIPS
Wu et al, 2009 [22]	263	227	36	66/175/117^a	NA	NA	NA	Combined (coils, gelatin sponge)	After TIPS
Tesdal et al, 2006 [11]	95	42	53	13/22/7	21/26/6	NA	NA	Bare	Combined (coils, sclerosing agent)	After TIPS

Table 2. Baseline Patients Characteristics of the Included Studies

Study, year

No. of patients

TIPS alone (n)

TIPS + embolization (n)

Child score in TIPS alone (A/B/C)

Child score in TIPS + embolization (A/B/C)

Varices location

Stent type

Embolic agents

Time of embolization in relation to TIPS

TIPS alone

TIPS + embolization

^aInclude both groups. GEV: gastroesophageal varices; TIPS: transjugular intrahepatic portosystemic shunt; IGV: isolated gastric varices; NA: not available.

Lv et al, 2022 [17]

134

31/26/8

38/27/4

Esophagus: 21/GEV1: 33/GEV2: 11

Esophagus: 23 /GEV1: 34/GEV2: 12

Covered

Coils

After TIPS

Yu et al, 2019 [14]

14/11/2

21/24/10

GEV2: 22/IGV1: 5

GEV2: 34/IGV1: 21

Covered

Combined (coils, vascular plug, sclerosing agent)

After TIPS

Zheng et al, 2016 [21]

Esophageal and gastric fundus varices

Combined (covered and bare)

Combined (coils, sclerosing agent)

After TIPS

Lakhoo et al, 2016 [15]

Covered

Combined (coils, vascular plug)

After TIPS

Shi et al, 2014 [16]

101

11/28/9

16/29/8

Esophageal and gastric fundus varices

Covered

Sclerosing agents

Before TIPS

Chen et al, 2013 [10]

106

9/40/3

12/37/5

Covered

Coils

Before TIPS

Xiao et al, 2011 [9]

14/18/4

15/20/8

Esophageal: 23/fundus: 13

Esophageal: 25/fundus: 18

Bare

Combined (coils, α-cyanoacrylate)

After TIPS

Xue et al, 2011 [13]

37/22/21^a

Esophageal: 29/fundus: 11

Esophageal: 10/fundus: 17

Combined (covered and bare)

Coils or ethanol

unspecified

Gaba et al, 2010 [12]

6/28/18^a

Esophageal: 24/gastric: 13

Esophageal: 7/gastric: 8

Covered

Coils

After TIPS

Wu et al, 2009 [22]

263

227

66/175/117^a

Combined (coils, gelatin sponge)

After TIPS

Tesdal et al, 2006 [11]

13/22/7

21/26/6

Bare

Combined (coils, sclerosing agent)

After TIPS