Letter to the Editor: “Comparison of TIPS alone and combined with partial splenic embolization (PSE) for the management of variceal bleeding”

by Xiaoze Wang, Xuefeng Luo, Li Yang (xiaoze.wang@foxmail.com)

Comparison of TIPS alone and combined with partial splenic embolization (PSE) for the management of variceal bleeding.

Dear Editor,

Wan et al. recently compared transjugular intrahepatic portosystemic shunt (TIPS) with TIPS plus concomitant partial splenic embolization (PSE) on the long-term shunt patency and overall survival of TIPS-treated patients in European Radiology [1]. We appreciate the innovative work and contributions concerning TIPS procedure, but there are several issues about the study design and the result interpretation may need to be discussed.

First, variceal bleeding, as mentioned in the title and indicating TIPS for all enrolled patients, was not the outcome in this study. According to the trial design recommendations of Baveno VI Consensus, the primary outcomes in patients after variceal bleeding without additional complications should include variceal rebleeding [2]. Besides, a rise in the portosystemic pressure gradient (PPG) to ≥ 12mm Hg or a recurrence of the complication of portal hypertension has been generally acknowledged as an indication of TIPS dysfunction, following the definition in the study that the authors cited [3, 4]. But neither PPG rise nor variceal rebleeding was referred in the sections of methods and results.

Second, the authors did not clearly explain why the primary patency rates significantly improved with concomitant PSE. It is well known that rapid blood flow is an important factor in avoiding thrombosis. PSE reduces blood flow to the splenic vein, thereby reducing the total blood flow to the portal vein and the shunt to some extent. In theory, PSE will increase the risk of portal vein thrombosis and shunt dysfunction [5]. In addition, the authors used spring coils to embolize the main branch of the splenic artery, which is contrary to the conventionally recommended technique that terminal of splenic artery should be embolized with particles to make red pulp ischemia [6,7]. Consequently, hypersplenism may relapse after the development of collateral circulation and the improvement of thrombocytopenia or leukopenia may be limited. However, the white cell counts and platelet counts after the procedure were not reported in this study.

Third, routine anticoagulation after TIPS is not recommended except in patients with Budd-Chiari syndrome or massive thrombosis of portal vein [8]. However, according to the data shown in Table 1, all patients in the study received either post-TIPS anticoagulation or antiplatelet prophylaxis for thrombosis. It is noticed that more than 60% of patients in both groups took aspirin or clopidogrel, which is rarely used to prevent venous thrombosis in cirrhotic patients with low platelet counts [9].

In summary, further studies are required to define the appropriate role of combined therapy using TIPS and PSE before its application in clinical practice.