Pre-Emptive TIPS Versus Standard Care for Patients With Cirrhosis and Variceal Bleeding: Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Background Acute variceal bleeding remains a severe and potentially fatal complication in patients with cirrhosis and portal hypertension. Recent randomized controlled trials (RCTs) have demonstrated improved bleeding control and potential survival benefits when a transjugular intrahepatic portosystemic shunt (TIPS) is placed early, within 24-72 h of admission (p-TIPS). Hence, this meta-analysis aims to evaluate the potential of p-TIPS in achieving a better survival rate, preventing rebleeding, and reducing adverse events compared to the standard of care in the treatment of variceal bleeding in patients with cirrhosis.

Methods An extensive literature search was performed in PubMed (MEDLINE), Scopus, WOS, ClinicalTrials.gov, and CENTRAL up to 16 June 2025. A pooled analysis was conducted to combine multiple studies, using either risk ratios (RR) for dichotomous outcomes or mean differences (MD) for continuous outcomes, along with 95% confidence intervals. All statistical analyses were conducted using R version 4.3. PROSPERO ID: CRD420251106950.

Results Six RCTs and 424 patients were included. P-TIPS non-significantly increased the rate of overall survival at <6 weeks (RR: 1.11, 95% CI: [0.95; 1.31], P = 0.1942), at <1 year (RR: 1.22, 95% CI: [0.98; 1.51], P = 0.0688), and at long-term follow-up (RR:0.77, 95% CI: 0.23; 2.30, P = 0.5931). P-TIPS significantly decreased rebleeding rate at <6 weeks (RR: 0.15, 95% CI: [0.07; 0.34], P < 0.0001), and at final follow-up (RR: 0.38, 95% CI: [0.23; 0.63], P = 0.0002). Also, p-TIPS demonstrated a significant reduction in new/worsening ascites (RR: 0.50, 95% CI [0.34, 0.75], P = 0.0008), spontaneous bacterial peritonitis (RR: 0.19, 95% CI [0.05, 0.64], P = 0.0074), hepatorenal syndrome (RR: 0.37, 95% CI [0.15, 0.92], P = 0.03), and the composite outcome of rebleeding or death (RR: 0.27, 95% CI [0.14, 0.53], P = 0.0002) compared to standard care. Still, there was no significant difference between the two groups in terms of transplant-free survival, incidence of hepatic encephalopathy, number of RBC units transfused during follow-up, or length of hospital stay.

Conclusion In patients with cirrhosis and variceal bleeding, p-TIPS significantly decreased rebleeding rate across all time points, the incidence of new/worsening ascites, spontaneous bacterial peritonitis, hepatorenal syndrome, and a composite outcome of rebleeding or death compared with standard care.