Hepatic encephalopathy is not a contraindication to pre-emptive TIPS in high-risk patients with cirrhosis with variceal bleeding

Marika Rudler*, Virginia Hernández-Gea, Bogdan Dumitru Procopet, Alvaro Giráldez, Lucio Amitrano, Càndid Villanueva, Luis Ibañez, Gilberto Silva-Junior, Joan Genesca, Christophe Bureau, Jonel Trebicka, Rafael Bañares, Aleksander Krag, Elba Llop, Wim Laleman, Jose Maria Palazon, Jose Castellote, Susana Rodrigues, Lise Lotte Gluud, Carlos Noronha FerreiraNouria Canete, Manuel Rodríguez, Arnulf Ferlitsch, Jose Luis Mundi, Henning Gronbaek, Manuel Hernandez-Guerra, Romano Sassatelli, Alessandra Dell'Era, Marco Senzolo, Juan G. Abraldes, Manuel Romero-Gómez, Alexander Zipprich, Meritxell Casas, Helena Masnou, Hélène Larrue, Massimo Primignani, Frederik Nevens, Jose Luis Calleja, Remy Schwarzer, Christian Jansen, Marie Angèle Robic, Irene Conejo, Javier Martínez Gonzalez, Maria Vega Catalina, Agustín Albillos, Edilmar Alvarado, Maria Anna Guardascione, Maxime Mallet, Simona Tripon, Georgina Casanovas, Jaume Bosch, Juan Carlos Garcia-Pagan, Dominique Thabut

*Corresponding author for this work

Research output: Contribution to journalJournal articleResearchpeer-review


Background: A pre-emptive transjugular intrahepatic portosystemic shunt (pTIPS) reduces mortality in high-risk patients with cirrhosis (Child-Pugh C/B+active bleeding) with acute variceal bleeding (AVB). Real-life studies point out that <15% of patients eligible for pTIPS ultimately undergo transjugular intrahepatic portosystemic shunt (TIPS) due to concerns about hepatic encephalopathy (HE). The outcome of patients undergoing pTIPS with HE is unknown. We aimed to (1) assess the prevalence of HE in patients with AVB; (2) evaluate the outcome of patients presenting HE at admission after pTIPS; and (3) determine if HE at admission is a risk factor for death and post-TIPS HE. Patients and methods: This is an observational study including 2138 patients from 34 centres between October 2011 and May 2015. Placement of pTIPS was based on individual centre policy. Patients were followed up to 1 year, death or liver transplantation. Results: 671 of 2138 patients were considered at high risk, 66 received pTIPS and 605 endoscopic+drug treatment. At admission, HE was significantly more frequent in high-risk than in low-risk patients (39.2% vs 10.6%, p<0.001). In high-risk patients with HE at admission, pTIPS was associated with a lower 1-year mortality than endoscopic+drug (HR 0.374, 95% CI 0.166 to 0.845, p=0.0181). The incidence of HE was not different between patients treated with pTIPS and endoscopic+drug (38.2% vs 38.7%, p=0.9721), even in patients with HE at admission (56.4% vs 58.7%, p=0.4594). Age >56, shock, Model for End-Stage Liver Disease score >15, endoscopic+drug treatment and HE at admission were independent factors of death in high-risk patients. Conclusion: pTIPS is associated with better survival than endoscopic treatment in high-risk patients with cirrhosis with variceal bleeding displaying HE at admission.

Original languageEnglish
Issue number4
Pages (from-to)749-758
Publication statusPublished - Apr 2023


  • cirrhosis
  • hepatic encephalopathy
  • oesophageal varices
  • Liver Cirrhosis/complications
  • Severity of Illness Index
  • End Stage Liver Disease
  • Humans
  • Hepatic Encephalopathy/etiology
  • Esophageal and Gastric Varices/complications
  • Gastrointestinal Hemorrhage/etiology
  • Contraindications


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