A prospective, randomized controlled trial of transjugular intrahepatic portosystemic shunt versus cyanoacrylate injection in the prevention of gastric variceal rebleeding

Background and study aims: Both endoscopic obturation and transjugular intrahepatic porto-systemic shunts (TIPSs) have proven to be effective in preventing rebleeding from gastric varices. This study compared the efficacy and complications of these modalities. Patients and methods: Cirrhotic patients with acute bleeding from gastric varices were considered for inclusion. After initial control, eligible patients were randomly allocated to two groups: TIPS (n = 35) and obturation using cyanoacrylate (n=37). In the cyanoacrylate group, treatment was repeated regularly until gastric varices were obliterated. Patients of both groups received regular follow-up. The end points were gastric variceal rebleeding or death. Results: Stent shunt insertion was successful in all TIPS patients, and mean portal pressure gradient decreased from 21.4 +/- 7.5 mm Hg to 7.5 +/- 3.5 mm Hg (P < 0.001). Variceal obliteration was achieved in 19 patients in the cyanoacrylate group (51%) compared with seven TIPS patients (20%) (P < 0.02). After a median follow up of 33 months, upper gastrointestinal bleeding occurred in 15 TIPS patients (43%) and 22 cyanoacrylate patients (59%) (P =0.12). Rebleeding from gastric varices was encountered in four TIPS patients (11 %) and 14 cyanoacrylate patients (38%)(P = 0.014; odds ratio 3.6, 95% CI 1.2- 11.1). Blood transfusion requirements were lower in the TIPS group than in the cyanoacrylate group (P < 0.01). Survival and frequency of complications were similar in both groups. Conclusions: TIPS proved more effective than glue injection in preventing rebleeding from gastric varices, with similar survival and frequency of complications.