Pre‐Emptive TIPS for Acute Variceal Bleeding: A Systematic Review and Meta‐Analysis of Randomized Controlled Trials

Abstract

Background There is evolving evidence regarding whether pre‐emptive transjugular intrahepatic portosystemic shunt (p‐TIPS) improves outcomes in patients with acute variceal bleeding. This meta‐analysis is aimed at evaluating the effectiveness of p‐TIPS compared with standard care in reducing mortality and rebleeding in high‐risk patients with cirrhosis. Methods We systematically searched CENTRAL, MEDLINE, Embase, and ClinicalTrials.gov to identify randomized controlled trials (RCTs) comparing p‐TIPS placed within 72 h of admission with standard care. All statistical analyses were performed using RevMan Version 5.4. Results Six RCTs (n = 424 participants) met inclusion criteria. p‐TIPS significantly reduced all‐cause mortality (RR 0.54, 95% CI 0.39–0.76; ARR 14.9%; NNT ≈ 7) and rebleeding (RR 0.29, 95% CI 0.16–0.55; ARR 28.4%; NNT ≈ 4) compared with standard care, with consistent effects across variceal subtypes and degrees of hepatic decompensation. p‐TIPS also significantly reduced new or worsening ascites (RR 0.51, 95% CI 0.35–0.74), hepatorenal syndrome (RR 0.37, 95% CI 0.15–0.92), liver‐related mortality (RR 0.56, 95% CI 0.34–0.94), and serious adverse events (RR 0.72, 95% CI 0.59–0.88), without increasing hepatic encephalopathy (RR 1.01, 95% CI 0.72–1.43). Conclusions p‐TIPS significantly reduced mortality and rebleeding risk in high‐risk patients with acute variceal bleeding, without increasing encephalopathy risk. These findings support its broader integration into clinical practice guidelines. Further large‐scale RCTs with extended follow‐up are warranted to define optimal patient selection, particularly in gastric variceal subgroups. PROSPERO: CRD420261329675