Transjugular Intrahepatic Portosystemic Shunt versus Percutaneous Transhepatic Variceal Embolization for Esophageal-Gastric Variceal Bleeding in Rural China: A Retrospective Cohort Study Focusing on Survival and Rebleeding

Transjugular Intrahepatic Portosystemic Shunt versus Percutaneous Transhepatic Variceal Embolization for Esophageal-Gastric Variceal Bleeding in Rural China: A Retrospective Cohort Study Focusing on Survival and Rebleeding | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Transjugular Intrahepatic Portosystemic Shunt versus Percutaneous Transhepatic Variceal Embolization for Esophageal-Gastric Variceal Bleeding in Rural China: A Retrospective Cohort Study Focusing on Survival and Rebleeding Tiangu Yang, Wei Liu, Xiaowei Sun, Yanhua Wang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8143939/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Esophageal-gastric variceal bleeding (EGVB) secondary to portal hypertension (PH) poses a greater therapeutic challenge in rural China. Patients often present with more severe conditions, including a high prevalence of portal vein thrombosis, tumor thrombi, and cavernous transformation of the portal vein (CTPV), making conventional treatments less effective. Methods This retrospective cohort study analyzed data from EGVB patients in rural Eastern China (Qingdao) who underwent interventional therapy between January 2021 and December 2024.Patients were divided into a Transjugular Intrahepatic Portosystemic Shunt (TIPS) group and a Percutaneous Transhepatic Gastric Variceal Embolization (PTVE) group. The primary outcomes were overall survival (OS), rebleeding intervals, and the incidence of hepatic encephalopathy (HE). Results The median OS was significantly longer in the TIPS group compared to the PTVE group (23.0 months vs. 4.5 months). The rebleeding interval was also significantly longer in the TIPS group. Hepatic encephalopathy occurred exclusively in the TIPS group, with a two-year cumulative incidence of 28.17%. The two-year stent dysfunction rate in the TIPS group was 8.5%. Conclusion For eligible EGVB patients in rural China, TIPS is significantly superior to PTVE in improving long-term survival and preventing rebleeding. Therefore, TIPS should be considered the preferred treatment strategy, although careful monitoring and management of hepatic encephalopathy are essential. Transjugular Intrahepatic Portosystemic Shunt (TIPS) Percutaneous Transhepatic Gastric Variceal Embolization (PTVE) Esophageal-gastric variceal bleeding (EGVB) portal hypertension (PH) Rural areas Figures Figure 1 Figure 2 Introduction Portal hypertension (PH) is a clinical syndrome characterized by a persistent pathological increase in portal venous pressure. It is most commonly caused by various forms of cirrhosis, and less frequently results from obstruction of the main portal vein or hepatic veins, or other idiopathic factors. Esophagogastric variceal bleeding (EGVB) represents the most lethal complication of PH, with approximately 40% of patients succumbing to the initial bleeding episode and a two-year rebleeding rate as high as 70% 1 . In rural China, constrained by economic limitations, health beliefs, and healthcare policies, patients often present with more severe manifestations of EGVB. These cases are frequently complicated by concomitant portal vein thrombosis or tumor thrombi, hepatocellular carcinoma, and cavernous transformation of the portal vein (CTPV). Such complex pathologies often render pharmacological and endoscopic therapies ineffective 2 .In recent years, interventional techniques have been widely adopted for managing EGVB. The most prevalent clinical interventions are Transjugular Intrahepatic Portosystemic Shunt (TIPS) and Percutaneous Transhepatic Gastric Coronary Vein Embolization (PTVE). However, most existing studies are based on urban populations with better healthcare access or clinical trials, which typically exclude patients with complex portal venous pathologies, such as extensive thrombosis or cavernous transformation. Consequently, high-quality evidence regarding the comparative effectiveness and safety of TIPS versus PTVE remains scarce for rural Chinese settings, where patients face limited medical resources and exhibit more complex disease profiles. This study aims to address this gap by conducting a retrospective cohort analysis of EGVB patients who underwent interventional therapy over the past four years in rural Eastern China (Shandong, Qingdao).The findings are intended to inform clinical practice and decision-making for this specific patient population. Materials and Methods Study Population ​​ A retrospective analysis was conducted on patients with esophagogastric variceal bleeding (EGVB) secondary to portal hypertension who were admitted to The Affiliated Hospital of Qingdao University (Pingdu) between January 2021 and December 2024. Inclusion criteria were: Radiologically confirmed EGVB with poor response to pharmacological or endoscopic therapy; General eligibility for interventional procedures without absolute contraindications; Child-Pugh class A or B liver function; Signed informed consent obtained from patients or their families. Exclusion criteria included: Severe impairment of hepatic, renal, cardiac, or pulmonary function rendering the patient unfit for intervention; Hepatocellular carcinoma at BCLC stage D; Incomplete follow-up data or loss to follow-up. Interventional Procedures Risks, complications, potential adverse effects, costs, and expected outcomes of both TIPS and PTVE were thoroughly explained to patients and their families, who subsequently chose the intervention. For PTVE, the NAPS-100 liver access needle (Cook Medical®) was used to puncture an intrahepatic portal branch. A 5F vascular sheath (Terumo®) was introduced, and various angiographic catheters were employed to selectively catheterize the target varices. Embolization was performed using the Interlock detachable fibered coil system (Boston Scientific®) in combination with free coils (Cook Medical®) and NBCA medical glue (Glubran®2). The procedure concluded after tract embolization. For TIPS, the RUPS-100 transjugular access set (Cook Medical®) was used to access an intrahepatic portal vein. Varices were embolized using the same technique as in PTVE. Subsequently, an 8–10 mm diameter-controlled, dedicated covered stent system (Gore®) was deployed to establish shunt. Post-deployment, the stent was gradually dilated based on portal pressure gradient (PPG) measurements. Postoperatively, anticoagulants were administered to maintain stent patency, and long-term oral ammonia-lowering agents were prescribed to reduce the risk of hepatic encephalopathy. Outcome Measures ​​ The following data were recorded: surgical method, age, gender, hospital stay, preoperative bleeding amount, preoperative and postoperative heart rate (HR) and blood pressure (BP),history of chronic hepatitis B and alcohol, history of malignancy, presence of portal vein thrombosis or cavernous transformation, spontaneous shunts, portal pressure gradient (PPG),hepatic and portal vein puncture sites, number of varices, and laboratory values at admission,discharge,1 month,3 months, and 6 months postoperatively — including hemoglobin (HB), platelet count (PLT), prothrombin time (PT),fibrinogen (FIB),alanine aminotransferase (ALT), and aspartate aminotransferase (AST). Outcomes analyzed included rebleeding events and intervals, incidence of hepatic encephalopathy (HE), stent dysfunction, mortality, overall survival (OS), and causes of death. Statistical Analysis​ ​ Data were analyzed using SPSS version 26.0. Paired samples were compared using the Wilcoxon signed-rank test. Intergroup comparisons were performed using the χ² test or Fisher’s exact test, as appropriate. Non-parametric tests were applied to categorical data. Binary and ordinal logistic regression models were used to evaluate efficacy and influencing factors. Receiver operating characteristic (ROC) curve analysis was conducted to assess predictive performance. A two-sided p-value < 0.05 was considered statistically significant. ​​Results​ Comparison of Baseline Characteristics between TIPS and PTVE Groups A comparison of baseline characteristics between the Transjugular Intrahepatic Portosystemic Shunt (TIPS) and Percutaneous Transhepatic Gastric Variceal Embolization (PTVE) groups revealed no statistically significant differences (P > 0.05) in terms of bleeding volume, history of malignancy, liver function classification (Child-Pugh grade),gender, heart rate, blood pressure, degree of anemia, history of hepatitis B virus infection, history of alcohol consumption, grade of portal vein thrombosis, or presence of spontaneous portosystemic shunts. This indicates that the two groups were comparable at baseline. Furthermore, the two groups were well-balanced regarding age, coagulation function, renal function, and cardiac function indicators. A statistically significant difference was observed only in alanine aminotransferase (ALT) levels; however, the median values for both groups fell within the upper limit of the normal range. The overall homogeneity in baseline demographics and clinical profiles between the groups suggests that subsequent comparisons of treatment efficacy and safety are reliable. (Table 1) Comparison of Laboratory Findings Before and After Intervention Therapy Laboratory parameters were compared at different time points: preoperatively, at discharge, and at 1,3, and 6 months postoperatively. Compared to preoperative levels, results at discharge showed a statistically significant decrease in platelet (PLT) count, prolongation of prothrombin time (PT),an increase in the International Normalized Ratio (INR),and elevated levels of alanine aminotransferase (ALT) and aspartate aminotransferase (AST).At the 1-month follow-up, significant improvements were observed, marked by a notable increase in hemoglobin (HB),red blood cell (RBC) count, and fibrinogen (FIB) levels. These positive trends continued at 3 months, with further increases in HB, FIB, and albumin (ALB). By 6 months postoperatively, HB levels showed continued improvement, and PLT counts demonstrated a significant increase. These changes across the specified time points were statistically significant. No statistically significant differences were found in the other laboratory parameters measured (Figure 1). Analysis of Risk Factors for Rebleeding, Hepatic Encephalopathy, and Stent Dysfunction Analysis of risk factors identified the severity of portal vein thrombosis and the degree of varices as showing a statistically significant association with rebleeding. Patients with portal vein thrombosis had a higher probability of rebleeding compared to those without thrombosis. This risk was further elevated in patients with cavernous transformation of the portal vein (CTPV). Additionally, a greater number of variceal veins was correlated with an increased likelihood of rebleeding. No other factors demonstrated a statistically significant association with rebleeding. For the interval between rebleeding episodes, statistically significant influencing factors included the severity of thrombosis and the type of surgical intervention. A shorter rebleeding interval was significantly associated with the presence of CTPV compared to portal vein thrombosis alone. Furthermore, patients who underwent PTVE had a significantly shorter rebleeding interval than those treated with TIPS. All cases of hepatic encephalopathy (HE) occurred exclusively in the TIPS group. The cumulative incidence of HE was 14.08% within 6 months, 21.13% within 1 year, and 28.17% within 2 years. The stent dysfunction rate in the TIPS group was 8.5% over the two-year follow-up period. No statistically significant risk factors were identified for the occurrence of HE or stent dysfunction (Table 2). Analysis of Risk Factors for Overall Survival A statistically significant difference in overall survival (OS) was observed between the two surgical approaches. The median survival time was approximately 23.0 months for patients who underwent TIPS, compared to 4.5 months for those who received PTVE, indicating a significant survival benefit favoring TIPS (Table 3). Analysis of risk factors impacting OS included the type of procedure, presence of malignancy, severity of portal vein thrombosis, occurrence and interval of rebleeding, incidence of hepatic encephalopathy, and stent dysfunction. Among these, the surgical procedure (TIPS vs. PTVE), presence of malignancy, and rebleeding interval demonstrated statistically significant associations with OS (Table 4). Further analysis of the procedure type, pre- and post-shunt pressure gradient (PPG), presence of tumor, and thrombus severity revealed that patients who underwent TIPS, had a PPG>20cmH 2 O, were tumor-free, and had no thrombosis achieved better OS. Conversely, patients treated with PTVE, presenting with a PPG<10cmH 2 O, concomitant malignancy, or cavernous transformation of the portal vein had a poorer prognosis and significantly shorter OS (Figure 2). The causes of death were categorized and included liver failure (33.3%), gastrointestinal bleeding (19.4%), hepatic encephalopathy (13.9%), abdominal infection (5.6%), and intra- or postoperative complications (5.6%), among others. Discussion Compared to their urban counterparts, rural residents often face challenges in healthcare, including limited health awareness, heavier economic burdens, and relatively scarce medical resources. These factors frequently lead to delays in seeking treatment and disease progression. In the context of PH-induced EGVB, this translates to patients presenting with a longer, previously uncontrolled disease course, more severe bleeding episodes, greater blood loss, and a critical overall condition. Our study cohort reflected this unique profile: 50.5% of patients had varying degrees of portal vein thrombosis or tumor thrombi, 16.5% had concomitant CTPV, and 34.1% had comorbid hepatocellular carcinoma. These characteristics differ significantly from populations typically enrolled in conventional clinical studies or urban-based cohorts, substantially impacting disease prognosis. TIPS, as a primary treatment for EGVB, has advanced rapidly in recent years. The widespread adoption of covered stents, compared to bare stents, reduces shunt dysfunction. The use of dedicated TIPS stents like VIATORR is associated with higher shunt patency rates, enabling sustained control of portal pressure and prolonged intervals between rebleeding episodes 3 – 4 . PTVE, as an alternative for managing EGVB, achieves excellent immediate hemostasis, playing a vital life-saving role. However, embolization of varices can further increase portal pressure, elevating the short-term risk of rebleeding. Consequently, PTVE often needs to be combined with other procedures like TIPS or partial splenic embolism (PSE) to reduce portal pressure for long-term prognosis 5 – 6 . In this study, both TIPS and PTVE led to short-term decreases in platelet counts and impaired coagulation function, likely related to significant blood loss 7 .The observed liver function impairment is attributable to reduced hepatic perfusion following either PTVE or TIPS shunt creation. These parameters generally improved significantly one month postoperatively, returning to near-preoperative levels, while markers like HB, RBC, FIB, and ALB showed notable recovery, indicating a return to a more stable physiological state. This also highlights the higher prerequisite for liver function reserve before TIPS; patients with severely compromised liver function preoperatively are at increased risk of acute liver failure post-TIPS 8 . For such patients, salvage therapies like PTVE or endoscopy are recommended for acute hemostasis, with consideration for a staged TIPS procedure after liver function recovery to minimize surgical risk and achieve better long-term outcomes 9 . The significant extension of the rebleeding interval by TIPS is consistent with its mechanism of effectively reducing portal pressure. In contrast, PTVE, by increasing portal pressure, leads to a shorter rebleeding interval 10 .The degree of varices was an independent risk factor for rebleeding. Even after successful TIPS, patients with severe vascular pathologies like CTPV exhibit complex post-procedural portal hemodynamics, necessitating closer follow-up and monitoring 11 .On the other hand, hepatic encephalopathy (HE), the most notable complication after TIPS, had a cumulative incidence of 28.17% over two years in our study, aligning with international reports 12 .All HE cases occurred in the TIPS group, underscoring the fundamental hemodynamic difference between the procedures: the portosystemic shunt created by TIPS is the pathophysiological basis for HE. Therefore, precise preoperative assessment of HE risk, intraoperative controlled dilation of the shunt diameter and PPG, stringent postoperative management are key to maximizing TIPS benefits while mitigating risks. The advent of diameter-controlled dedicated TIPS stents allows for initial deployment at a smaller diameter upon achieving satisfactory pressure reduction, potentially lowering HE risk 13 .The stent can be progressively dilated later if shunt insufficiency occurs, balancing HE risk against controlling the efficacy of portal pressure 14 .The relatively low 2-year stent dysfunction rate of 8.5% in our TIPS cohort underscores the superior performance of VIATORR stents in maintaining shunt patency, regular postoperative follow-up ultrasound to assess the blood flow velocity within the stent is also a simple method for judging the function of the stent, it’s two crucial factors for the improving long-term efficacy of TIPS 15 – 16 . Our study demonstrates that patients receiving TIPS had significantly longer OS compared to those receiving PTVE alone (23.0 vs. 4.5 months).This finding is consistent with several prospective studies, confirming that TIPS controls bleeding risk etiologically by reducing portal pressure, while also improving splanchnic congestion and aiding ascites control, thereby improving long-term prognosis 17 – 19 .The notably poorer prognosis in our PTVE group compared to some other studies, also reflecting the advanced disease stage and limited access to subsequent definitive treatments due to financial constraints in this rural population. Recent adjustments to health insurance policies and reduced costs of medical materials in China are improving healthcare access for rural residents. Based on our findings, TIPS should be the preferred strategy for preventing rebleeding and improving long-term survival in eligible EGVB patients in rural China. However, treatment decisions must be individualized, considering local hospital capabilities, operator expertise, and patients' financial circumstances. We propose a stratified management strategy: 1) First-line Strategy: For patients with Child-Pugh A/B liver function and suitable portal vein anatomy, TIPS using dedicated covered stents should be actively recommended for durable efficacy 20 . 2) Salvage/Bridge Strategy: For patients with acute massive bleeding, hemodynamic instability, or when TIPS is not immediately feasible, PTVE serves as a rapid hemostatic "bridge procedure 21 ". Once stabilized, patients should be evaluated for staged TIPS to address the underlying portal hypertension. 3) Combined Strategy: For patients at high risk of rebleeding (e.g., severe varices/CTPV) or HE, combining a small-diameter TIPS with PSE could be explored. PSE reduces portal inflow, potentially aiding pressure reduction without over-reliance on the shunt, possibly balancing bleeding and HE risks 22 . This study has limitations inherent to its single-center, retrospective design. Non-randomized group allocation introduces selection bias, potentially overestimating the absolute benefit of TIPS. The relatively limited sample size may constrain the statistical power of multivariate analyses. Future multi-center, large-sample prospective studies, incorporating health economic evaluations, are needed to validate the optimal treatment pathway for this specific rural context in China. Conclusion In conclusion, patients with portal hypertension-induced EGVB in rural China often present with more complex and severe disease. TIPS demonstrated superior efficacy over PTVE in prolonging overall survival and preventing rebleeding; however, it necessitates vigilant monitoring and management of hepatic encephalopathy. Clinical decision-making should be guided by the patient's specific portal venous pathology, hepatic functional reserve, and local medical resources to formulate an individualized interventional strategy. Enhancing early screening and intervention for liver diseases in rural areas, along with improving accessibility to advanced techniques like TIPS, is crucial for improving outcomes in this population. Declarations Ethics approval and consent to participate The study protocol was approved by the Ethics Committee of the Affiliated Hospital of Qingdao University. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The Ethics Committee waived the requirement for informed consent due to the retrospective nature of the study and the anonymization of patient data. Consent for publication Not applicable. Availability of data and materials The datasets generated and/or analyzed during the current study are not publicly available due to patient privacy but are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Authors' contributions Tiangu Yangwas the principal investigator and primary driver of the study. He was primarily responsible for the conceptualization and design of the research protocol. Furthermore, he took the lead in drafting the initial manuscript and played a central role in the critical revision and editing of the article for important intellectual content. Wei Liumade a substantial contribution to the empirical aspect of the research. His primary responsibilities included the systematic collection and assembly of the clinical data. He also performed the initial data analysis, ensuring the integrity of the dataset used for the study's conclusions. Xiaowei Sunwas instrumental in validating the analytical findings. His key role involved the verification and validation of the data analyzed, ensuring accuracy and reproducibility. He provided additional expertise by conducting supplementary statistical analyses to strengthen the robustness of the results. Yanhua Wang, as the corresponding author, provided overall supervision and guidance throughout the project. He was responsible for the final review and approval of the manuscript, offering critical feedback and strategic suggestions for improvement. His role also included synthesizing and interpreting the results to form a coherent conclusion. All authors have reviewed and approved the final version of the manuscript and agree to be accountable for all aspects of the work. 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Epub 2021 Jul 15. PMID: 34274511; PMCID: PMC8760361. Li GQ, Yang B, Liu J, Wang GC, Yuan HP, Zhao JR, Liu JY, Li XP, Zhang CQ. Hepatic venous pressure gradient is a useful predictor in guiding treatment on prevention of variceal rebleeding in cirrhosis. Int J Clin Exp Med. 2015 Oct 15;8(10):19709-16. PMID: 26770635; PMCID: PMC4694535. Schultz G, Naas M, Webb J. Use of Partial Splenic Embolization Following a Transjugular Intrahepatic Portosystemic Shunt to Reduce Persistent Portal Hypertension Sequelae. Cureus. 2025 Aug 7;17(8):e89540. doi: 10.7759/cureus.89540. PMID: 40918905; PMCID: PMC12413769. Tables Tables 1 to 4 are available in the Supplementary Files section. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8143939","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":554925669,"identity":"8c4fd12a-9ad3-4033-97d2-3d476de2b34e","order_by":0,"name":"Tiangu Yang","email":"","orcid":"","institution":"The Affiliated Hospital of Qingdao University","correspondingAuthor":false,"prefix":"","firstName":"Tiangu","middleName":"","lastName":"Yang","suffix":""},{"id":554925672,"identity":"1dccdb9c-0800-4ab2-ab8e-7c6d784c2246","order_by":1,"name":"Wei Liu","email":"","orcid":"","institution":"Qingdao Municipal Center For Disease Control and Prevention","correspondingAuthor":false,"prefix":"","firstName":"Wei","middleName":"","lastName":"Liu","suffix":""},{"id":554925677,"identity":"87183c1f-d3f3-49e9-90ae-f9d72b64d504","order_by":2,"name":"Xiaowei Sun","email":"","orcid":"","institution":"Qingdao Women and Children’s Hospital","correspondingAuthor":false,"prefix":"","firstName":"Xiaowei","middleName":"","lastName":"Sun","suffix":""},{"id":554925678,"identity":"b81e9c6c-150b-44b4-af33-f9f4032ea85f","order_by":3,"name":"Yanhua Wang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAwElEQVRIiWNgGAWjYDACCSB+YMDAwM/MfPAB8VoSDAwYJNvZkg1I0MJgwGBwnsdMgCgdBrd7DB8kFPyRMz7MYMbAUGMTTVjLnTPGBkCHGZsdZkh7wHAsLbeBoJYbudskgFoStx1mOG7A2HCYKC3bfwC11G9uZmyTIFbLNlCIJRgwM7MRp0XyRv5noMOMDWccZmM2SCDGL3w30hI/fPgjJ8/ff/7jgw81NoS1KBxA5iUQUg4C8gQNHQWjYBSMglEAAJcFP2J0FEybAAAAAElFTkSuQmCC","orcid":"","institution":"The Affiliated Hospital of Qingdao University","correspondingAuthor":true,"prefix":"","firstName":"Yanhua","middleName":"","lastName":"Wang","suffix":""}],"badges":[],"createdAt":"2025-11-18 09:53:54","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8143939/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8143939/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":97674896,"identity":"4855734a-d5aa-4d9b-b32b-7a605b605d26","added_by":"auto","created_at":"2025-12-08 09:44:39","extension":"jpg","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":355564,"visible":true,"origin":"","legend":"","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8143939/v1/3221b00d91e90e88397d76cb.jpg"},{"id":97656897,"identity":"9d6982c0-b022-4d1d-b4fd-7f3dca099f2b","added_by":"auto","created_at":"2025-12-08 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09:44:26","extension":"html","order_by":19,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":139115,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8143939/v1/9535cdc321fabe61504e0182.html"},{"id":97656898,"identity":"adf638d2-bff2-4c50-8260-fd21d3763ca6","added_by":"auto","created_at":"2025-12-08 07:14:09","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":355564,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of Laboratory Findings Before and After Intervention therapy\u003c/p\u003e\n\u003cp\u003e(A) Postoperative anemia is anticipated to improve over the course of recovery.\u003c/p\u003e\n\u003cp\u003e(B) Platelets are expended during acute hemorrhage, with subsequent gradual replenishment occurring in the postoperative period.\u003c/p\u003e\n\u003cp\u003e(C) Red blood cell counts decrease following acute blood loss, followed by a return to pre-hemorrhage levels in the postoperative period.\u003c/p\u003e\n\u003cp\u003e(D) Prothrombin time will remain elevated postoperatively due to the administration of oral anticoagulants.\u003c/p\u003e\n\u003cp\u003e(E) The perioperative trajectory of fibrinogen is characterized by an initial consumption during bleeding and a subsequent slow recovery after surgery..\u003c/p\u003e\n\u003cp\u003e(F) Elevated ALT and AST levels, serving as a marker for hepatic impairment due to reduced intraoperative blood flow, are expected to normalize within one month after surgery.\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8143939/v1/1ba18ca9334dda6ac0727436.jpg"},{"id":97673231,"identity":"e4f44c31-de60-44dd-9556-d6afe71699a8","added_by":"auto","created_at":"2025-12-08 09:39:42","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":733014,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan-Meier survival analysis of overall survival (OS) based on key prognostic factors.\u003c/p\u003e\n\u003cp\u003e(A) OS stratified by the presence or absence of tumor. Patients without tumor had significantly better survival outcomes (log-rank p\u0026lt;0.001).\u003c/p\u003e\n\u003cp\u003e(B) OS stratified by the portal pressure gradient (PPG) difference after shunt creation. Patients with a higher PPG reduction (Higher lobe) demonstrated significantly improved survival compared to those with a lower reduction (Lower lobe) (log-rank p\u0026lt;0.001).\u003c/p\u003e\n\u003cp\u003e(C) OS comparison between the two surgical procedures. Patients in the Transjugular Intrahepatic Portosystemic Shunt (TIPS) group had a significantly longer overall survival than those in the Percutaneous Transhepatic Variceal Embolization (PTVE) group (log-rank p\u0026lt;0.001).\u003c/p\u003e\n\u003cp\u003e(D) OS stratified by the severity of portal vein thrombosis. Patients without thrombosis had a more favorable prognosis compared to those with thrombosis (log-rank p\u0026lt;0.05).\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8143939/v1/1be3b4bf071ab38bce0b3db7.jpg"},{"id":102636451,"identity":"ea2f51ce-1173-4a5a-80c5-f50654cba52a","added_by":"auto","created_at":"2026-02-13 22:23:55","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1708895,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8143939/v1/caf5abc3-93e8-498a-876f-3d3afd4eb8a7.pdf"},{"id":97656895,"identity":"c07939e2-f330-42c0-987a-d1b33a35c2c0","added_by":"auto","created_at":"2025-12-08 07:14:09","extension":"xlsx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":49463,"visible":true,"origin":"","legend":"","description":"","filename":"RawData.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-8143939/v1/743530054913dd91d7129ada.xlsx"},{"id":97656896,"identity":"343150df-09d2-493d-ba92-c5bd25359218","added_by":"auto","created_at":"2025-12-08 07:14:09","extension":"jpg","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":374027,"visible":true,"origin":"","legend":"","description":"","filename":"table1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8143939/v1/8d5b623fb96c8bb8b1b9dff0.jpg"},{"id":97656903,"identity":"37ba58ff-1e93-4f6b-be6d-6ab361ad7287","added_by":"auto","created_at":"2025-12-08 07:14:09","extension":"jpg","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":367891,"visible":true,"origin":"","legend":"","description":"","filename":"table2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8143939/v1/f06572351d52f3b788f314d2.jpg"},{"id":97673016,"identity":"a4cff99e-abc1-47b3-b02e-3825d1f8a360","added_by":"auto","created_at":"2025-12-08 09:39:19","extension":"jpg","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":42927,"visible":true,"origin":"","legend":"","description":"","filename":"table3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8143939/v1/f19d535a5ac7f8eebf970872.jpg"},{"id":97656907,"identity":"bf989185-578f-45f9-9139-9cdf530e6f7c","added_by":"auto","created_at":"2025-12-08 07:14:09","extension":"jpg","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":137555,"visible":true,"origin":"","legend":"","description":"","filename":"table4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8143939/v1/f7534892c6fe5b499da8682d.jpg"}],"financialInterests":"No competing interests reported.","formattedTitle":"Transjugular Intrahepatic Portosystemic Shunt versus Percutaneous Transhepatic Variceal Embolization for Esophageal-Gastric Variceal Bleeding in Rural China: A Retrospective Cohort Study Focusing on Survival and Rebleeding","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePortal hypertension (PH) is a clinical syndrome characterized by a persistent pathological increase in portal venous pressure. It is most commonly caused by various forms of cirrhosis, and less frequently results from obstruction of the main portal vein or hepatic veins, or other idiopathic factors. Esophagogastric variceal bleeding (EGVB) represents the most lethal complication of PH, with approximately 40% of patients succumbing to the initial bleeding episode and a two-year rebleeding rate as high as 70%\u003csup\u003e1\u003c/sup\u003e. In rural China, constrained by economic limitations, health beliefs, and healthcare policies, patients often present with more severe manifestations of EGVB. These cases are frequently complicated by concomitant portal vein thrombosis or tumor thrombi, hepatocellular carcinoma, and cavernous transformation of the portal vein (CTPV). Such complex pathologies often render pharmacological and endoscopic therapies ineffective\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e.In recent years, interventional techniques have been widely adopted for managing EGVB. The most prevalent clinical interventions are Transjugular Intrahepatic Portosystemic Shunt (TIPS) and Percutaneous Transhepatic Gastric Coronary Vein Embolization (PTVE). However, most existing studies are based on urban populations with better healthcare access or clinical trials, which typically exclude patients with complex portal venous pathologies, such as extensive thrombosis or cavernous transformation. Consequently, high-quality evidence regarding the comparative effectiveness and safety of TIPS versus PTVE remains scarce for rural Chinese settings, where patients face limited medical resources and exhibit more complex disease profiles. This study aims to address this gap by conducting a retrospective cohort analysis of EGVB patients who underwent interventional therapy over the past four years in rural Eastern China (Shandong, Qingdao).The findings are intended to inform clinical practice and decision-making for this specific patient population.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e\u003cb\u003eStudy Population\u003c/b\u003e​​\u003c/p\u003e\u003cp\u003eA retrospective analysis was conducted on patients with esophagogastric variceal bleeding (EGVB) secondary to portal hypertension who were admitted to The Affiliated Hospital of Qingdao University (Pingdu) between January 2021 and December 2024.\u003c/p\u003e\u003cp\u003eInclusion criteria were:\u003c/p\u003e\u003cp\u003eRadiologically confirmed EGVB with poor response to pharmacological or endoscopic therapy;\u003c/p\u003e\u003cp\u003eGeneral eligibility for interventional procedures without absolute contraindications;\u003c/p\u003e\u003cp\u003eChild-Pugh class A or B liver function;\u003c/p\u003e\u003cp\u003eSigned informed consent obtained from patients or their families.\u003c/p\u003e\u003cp\u003eExclusion criteria included:\u003c/p\u003e\u003cp\u003eSevere impairment of hepatic, renal, cardiac, or pulmonary function rendering the patient unfit for intervention;\u003c/p\u003e\u003cp\u003eHepatocellular carcinoma at BCLC stage D;\u003c/p\u003e\u003cp\u003eIncomplete follow-up data or loss to follow-up.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eInterventional Procedures\u003c/h2\u003e\u003cp\u003eRisks, complications, potential adverse effects, costs, and expected outcomes of both TIPS and PTVE were thoroughly explained to patients and their families, who subsequently chose the intervention.\u003c/p\u003e\u003cp\u003eFor PTVE, the NAPS-100 liver access needle (Cook Medical\u0026reg;) was used to puncture an intrahepatic portal branch. A 5F vascular sheath (Terumo\u0026reg;) was introduced, and various angiographic catheters were employed to selectively catheterize the target varices. Embolization was performed using the Interlock detachable fibered coil system (Boston Scientific\u0026reg;) in combination with free coils (Cook Medical\u0026reg;) and NBCA medical glue (Glubran\u0026reg;2). The procedure concluded after tract embolization.\u003c/p\u003e\u003cp\u003eFor TIPS, the RUPS-100 transjugular access set (Cook Medical\u0026reg;) was used to access an intrahepatic portal vein. Varices were embolized using the same technique as in PTVE. Subsequently, an 8\u0026ndash;10 mm diameter-controlled, dedicated covered stent system (Gore\u0026reg;) was deployed to establish shunt. Post-deployment, the stent was gradually dilated based on portal pressure gradient (PPG) measurements. Postoperatively, anticoagulants were administered to maintain stent patency, and long-term oral ammonia-lowering agents were prescribed to reduce the risk of hepatic encephalopathy.\u003c/p\u003e\u003cp\u003e\u003cb\u003eOutcome Measures\u003c/b\u003e​​\u003c/p\u003e\u003cp\u003eThe following data were recorded: surgical method, age, gender, hospital stay, preoperative bleeding amount, preoperative and postoperative heart rate (HR) and blood pressure (BP),history of chronic hepatitis B and alcohol, history of malignancy, presence of portal vein thrombosis or cavernous transformation, spontaneous shunts, portal pressure gradient (PPG),hepatic and portal vein puncture sites, number of varices, and laboratory values at admission,discharge,1 month,3 months, and 6 months postoperatively \u0026mdash; including hemoglobin (HB), platelet count (PLT), prothrombin time (PT),fibrinogen (FIB),alanine aminotransferase (ALT), and aspartate aminotransferase (AST).\u003c/p\u003e\u003cp\u003eOutcomes analyzed included rebleeding events and intervals, incidence of hepatic encephalopathy (HE), stent dysfunction, mortality, overall survival (OS), and causes of death.\u003c/p\u003e\u003cp\u003e\u003cb\u003eStatistical Analysis​\u003c/b\u003e​\u003c/p\u003e\u003cp\u003eData were analyzed using SPSS version 26.0. Paired samples were compared using the Wilcoxon signed-rank test. Intergroup comparisons were performed using the χ\u0026sup2; test or Fisher\u0026rsquo;s exact test, as appropriate. Non-parametric tests were applied to categorical data. Binary and ordinal logistic regression models were used to evaluate efficacy and influencing factors. Receiver operating characteristic (ROC) curve analysis was conducted to assess predictive performance. A two-sided p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e\u003c/div\u003e"},{"header":"​​Results​","content":"\u003cp\u003e\u003cstrong\u003eComparison of Baseline Characteristics between TIPS and PTVE Groups\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA comparison of baseline characteristics between the Transjugular Intrahepatic Portosystemic Shunt (TIPS) and Percutaneous Transhepatic Gastric Variceal Embolization (PTVE) groups revealed no statistically significant differences (P \u0026gt; 0.05) in terms of bleeding volume, history of malignancy, liver function classification (Child-Pugh grade),gender, heart rate, blood pressure, degree of anemia, history of hepatitis B virus infection, history of alcohol consumption, grade of portal vein thrombosis, or presence of spontaneous portosystemic shunts. This indicates that the two groups were comparable at baseline. Furthermore, the two groups were well-balanced regarding age, coagulation function, renal function, and cardiac function indicators. A statistically significant difference was observed only in alanine aminotransferase (ALT) levels; however, the median values for both groups fell within the upper limit of the normal range.\u003c/p\u003e\n\u003cp\u003eThe overall homogeneity in baseline demographics and clinical profiles between the groups suggests that subsequent comparisons of treatment efficacy and safety are reliable. (Table 1)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComparison of Laboratory Findings Before and After Intervention Therapy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLaboratory parameters were compared at different time points: preoperatively, at discharge, and at 1,3, and 6 months postoperatively.\u003c/p\u003e\n\u003cp\u003eCompared to preoperative levels, results at discharge showed a statistically significant decrease in platelet (PLT) count, prolongation of prothrombin time (PT),an increase in the International Normalized Ratio (INR),and elevated levels of alanine aminotransferase (ALT) and aspartate aminotransferase (AST).At the 1-month follow-up, significant improvements were observed, marked by a notable increase in hemoglobin (HB),red blood cell (RBC) count, and fibrinogen (FIB) levels. These positive trends continued at 3 months, with further increases in HB, FIB, and albumin (ALB). By 6 months postoperatively, HB levels showed continued improvement, and PLT counts demonstrated a significant increase.\u003c/p\u003e\n\u003cp\u003eThese changes across the specified time points were statistically significant. No statistically significant differences were found in the other laboratory parameters measured (Figure 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAnalysis of Risk Factors for Rebleeding, Hepatic Encephalopathy, and Stent Dysfunction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAnalysis of risk factors identified the severity of portal vein thrombosis and the degree of varices as showing a statistically significant association with rebleeding. Patients with portal vein thrombosis had a higher probability of rebleeding compared to those without thrombosis. This risk was further elevated in patients with cavernous transformation of the portal vein (CTPV). Additionally, a greater number of variceal veins was correlated with an increased likelihood of rebleeding. No other factors demonstrated a statistically significant association with rebleeding.\u003c/p\u003e\n\u003cp\u003eFor the interval between rebleeding episodes, statistically significant influencing factors included the severity of thrombosis and the type of surgical intervention. A shorter rebleeding interval was significantly associated with the presence of CTPV compared to portal vein thrombosis alone. Furthermore, patients who underwent PTVE had a significantly shorter rebleeding interval than those treated with TIPS.\u003c/p\u003e\n\u003cp\u003eAll cases of hepatic encephalopathy (HE) occurred exclusively in the TIPS group. The cumulative incidence of HE was 14.08% within 6 months, 21.13% within 1 year, and 28.17% within 2 years. The stent dysfunction rate in the TIPS group was 8.5% over the two-year follow-up period. No statistically significant risk factors were identified for the occurrence of HE or stent dysfunction (Table 2).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAnalysis of Risk Factors for Overall Survival\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA statistically significant difference in overall survival (OS) was observed between the two surgical approaches. The median survival time was approximately 23.0 months for patients who underwent TIPS, compared to 4.5 months for those who received PTVE, indicating a significant survival benefit favoring TIPS (Table 3).\u003c/p\u003e\n\u003cp\u003eAnalysis of risk factors impacting OS included the type of procedure, presence of malignancy, severity of portal vein thrombosis, occurrence and interval of rebleeding, incidence of hepatic encephalopathy, and stent dysfunction. Among these, the surgical procedure (TIPS vs. PTVE), presence of malignancy, and rebleeding interval demonstrated statistically significant associations with OS (Table 4).\u003c/p\u003e\n\u003cp\u003eFurther analysis of the procedure type, pre- and post-shunt pressure gradient (PPG), presence of tumor, and thrombus severity revealed that patients who underwent TIPS, had a PPG\u0026gt;20cmH\u003csup\u003e2\u003c/sup\u003eO, were tumor-free, and had no thrombosis achieved better OS. Conversely, patients treated with PTVE, presenting with a PPG\u0026lt;10cmH\u003csup\u003e2\u003c/sup\u003eO, concomitant malignancy, or cavernous transformation of the portal vein had a poorer prognosis and significantly shorter OS (Figure 2).\u003c/p\u003e\n\u003cp\u003eThe causes of death were categorized and included liver failure (33.3%), gastrointestinal bleeding (19.4%), hepatic encephalopathy (13.9%), abdominal infection (5.6%), and intra- or postoperative complications (5.6%), among others.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eCompared to their urban counterparts, rural residents often face challenges in healthcare, including limited health awareness, heavier economic burdens, and relatively scarce medical resources. These factors frequently lead to delays in seeking treatment and disease progression. In the context of PH-induced EGVB, this translates to patients presenting with a longer, previously uncontrolled disease course, more severe bleeding episodes, greater blood loss, and a critical overall condition. Our study cohort reflected this unique profile: 50.5% of patients had varying degrees of portal vein thrombosis or tumor thrombi, 16.5% had concomitant CTPV, and 34.1% had comorbid hepatocellular carcinoma. These characteristics differ significantly from populations typically enrolled in conventional clinical studies or urban-based cohorts, substantially impacting disease prognosis.\u003c/p\u003e\u003cp\u003eTIPS, as a primary treatment for EGVB, has advanced rapidly in recent years. The widespread adoption of covered stents, compared to bare stents, reduces shunt dysfunction. The use of dedicated TIPS stents like VIATORR is associated with higher shunt patency rates, enabling sustained control of portal pressure and prolonged intervals between rebleeding episodes\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. PTVE, as an alternative for managing EGVB, achieves excellent immediate hemostasis, playing a vital life-saving role. However, embolization of varices can further increase portal pressure, elevating the short-term risk of rebleeding. Consequently, PTVE often needs to be combined with other procedures like TIPS or partial splenic embolism (PSE) to reduce portal pressure for long-term prognosis\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eIn this study, both TIPS and PTVE led to short-term decreases in platelet counts and impaired coagulation function, likely related to significant blood loss\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e.The observed liver function impairment is attributable to reduced hepatic perfusion following either PTVE or TIPS shunt creation. These parameters generally improved significantly one month postoperatively, returning to near-preoperative levels, while markers like HB, RBC, FIB, and ALB showed notable recovery, indicating a return to a more stable physiological state. This also highlights the higher prerequisite for liver function reserve before TIPS; patients with severely compromised liver function preoperatively are at increased risk of acute liver failure post-TIPS\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. For such patients, salvage therapies like PTVE or endoscopy are recommended for acute hemostasis, with consideration for a staged TIPS procedure after liver function recovery to minimize surgical risk and achieve better long-term outcomes\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThe significant extension of the rebleeding interval by TIPS is consistent with its mechanism of effectively reducing portal pressure. In contrast, PTVE, by increasing portal pressure, leads to a shorter rebleeding interval\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e.The degree of varices was an independent risk factor for rebleeding. Even after successful TIPS, patients with severe vascular pathologies like CTPV exhibit complex post-procedural portal hemodynamics, necessitating closer follow-up and monitoring\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e.On the other hand, hepatic encephalopathy (HE), the most notable complication after TIPS, had a cumulative incidence of 28.17% over two years in our study, aligning with international reports\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e.All HE cases occurred in the TIPS group, underscoring the fundamental hemodynamic difference between the procedures: the portosystemic shunt created by TIPS is the pathophysiological basis for HE. Therefore, precise preoperative assessment of HE risk, intraoperative controlled dilation of the shunt diameter and PPG, stringent postoperative management are key to maximizing TIPS benefits while mitigating risks. The advent of diameter-controlled dedicated TIPS stents allows for initial deployment at a smaller diameter upon achieving satisfactory pressure reduction, potentially lowering HE risk\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e.The stent can be progressively dilated later if shunt insufficiency occurs, balancing HE risk against controlling the efficacy of portal pressure\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e.The relatively low 2-year stent dysfunction rate of 8.5% in our TIPS cohort underscores the superior performance of VIATORR stents in maintaining shunt patency, regular postoperative follow-up ultrasound to assess the blood flow velocity within the stent is also a simple method for judging the function of the stent, it\u0026rsquo;s two crucial factors for the improving long-term efficacy of TIPS\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eOur study demonstrates that patients receiving TIPS had significantly longer OS compared to those receiving PTVE alone (23.0 vs. 4.5 months).This finding is consistent with several prospective studies, confirming that TIPS controls bleeding risk etiologically by reducing portal pressure, while also improving splanchnic congestion and aiding ascites control, thereby improving long-term prognosis\u003csup\u003e\u003cspan additionalcitationids=\"CR18\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e.The notably poorer prognosis in our PTVE group compared to some other studies, also reflecting the advanced disease stage and limited access to subsequent definitive treatments due to financial constraints in this rural population.\u003c/p\u003e\u003cp\u003eRecent adjustments to health insurance policies and reduced costs of medical materials in China are improving healthcare access for rural residents. Based on our findings, TIPS should be the preferred strategy for preventing rebleeding and improving long-term survival in eligible EGVB patients in rural China. However, treatment decisions must be individualized, considering local hospital capabilities, operator expertise, and patients' financial circumstances. We propose a stratified management strategy: 1) First-line Strategy: For patients with Child-Pugh A/B liver function and suitable portal vein anatomy, TIPS using dedicated covered stents should be actively recommended for durable efficacy\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. 2) Salvage/Bridge Strategy: For patients with acute massive bleeding, hemodynamic instability, or when TIPS is not immediately feasible, PTVE serves as a rapid hemostatic \"bridge procedure\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e\". Once stabilized, patients should be evaluated for staged TIPS to address the underlying portal hypertension. 3) Combined Strategy: For patients at high risk of rebleeding (e.g., severe varices/CTPV) or HE, combining a small-diameter TIPS with PSE could be explored. PSE reduces portal inflow, potentially aiding pressure reduction without over-reliance on the shunt, possibly balancing bleeding and HE risks\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThis study has limitations inherent to its single-center, retrospective design. Non-randomized group allocation introduces selection bias, potentially overestimating the absolute benefit of TIPS. The relatively limited sample size may constrain the statistical power of multivariate analyses. Future multi-center, large-sample prospective studies, incorporating health economic evaluations, are needed to validate the optimal treatment pathway for this specific rural context in China.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, patients with portal hypertension-induced EGVB in rural China often present with more complex and severe disease. TIPS demonstrated superior efficacy over PTVE in prolonging overall survival and preventing rebleeding; however, it necessitates vigilant monitoring and management of hepatic encephalopathy. Clinical decision-making should be guided by the patient's specific portal venous pathology, hepatic functional reserve, and local medical resources to formulate an individualized interventional strategy. Enhancing early screening and intervention for liver diseases in rural areas, along with improving accessibility to advanced techniques like TIPS, is crucial for improving outcomes in this population.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol was approved by the Ethics Committee of the Affiliated Hospital of Qingdao University. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The Ethics Committee waived the requirement for informed consent due to the retrospective nature of the study and the anonymization of patient data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during the current study are not publicly available due to patient privacy but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTiangu Yangwas the principal investigator and primary driver of the study. He was primarily responsible for the conceptualization and design of the research protocol. Furthermore, he took the lead in drafting the initial manuscript and played a central role in the critical revision and editing of the article for important intellectual content.\u003c/p\u003e\n\u003cp\u003eWei Liumade a substantial contribution to the empirical aspect of the research. His primary responsibilities included the systematic collection and assembly of the clinical data. He also performed the initial data analysis, ensuring the integrity of the dataset used for the study\u0026apos;s conclusions.\u003c/p\u003e\n\u003cp\u003eXiaowei Sunwas instrumental in validating the analytical findings. His key role involved the verification and validation of the data analyzed, ensuring accuracy and reproducibility. He provided additional expertise by conducting supplementary statistical analyses to strengthen the robustness of the results.\u003c/p\u003e\n\u003cp\u003eYanhua Wang, as the corresponding author, provided overall supervision and guidance throughout the project. He was responsible for the final review and approval of the manuscript, offering critical feedback and strategic suggestions for improvement. His role also included synthesizing and interpreting the results to form a coherent conclusion.\u003c/p\u003e\n\u003cp\u003eAll authors have reviewed and approved the final version of the manuscript and agree to be accountable for all aspects of the work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank the clinical and research teams at Department of Interventional Therapy in the Affiliated Hospital of Qingdao University for their support in data collection and patient care. The authors also thank the anonymous reviewers for their insightful comments.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWONG MELISSA，BUSUTTIL RONALD W. Surgery in Patients with Portal Hypertension[J].\u003cins cite=\"mailto:此木\" datetime=\"2025-10-22T15:14\"\u003e \u003c/ins\u003eClinics in Liver Disease, 2019, 23(4):755-780.\u003cins cite=\"mailto:此木\" datetime=\"2025-10-22T15:16\"\u003e \u003c/ins\u003eDOI:10.1016/j.cld.2019.07.003.\u003c/li\u003e\n\u003cli\u003eZhou Y, Zhuang Z, Yu T, Zhang W, Ma J, Yu J, Yan Z, Luo J. Long-term efficacy and safety of anticoagulant for cavernous transformation of the portal vein cirrhotic patient with extrahepatic portal vein obstruction. Thromb J. 2023 Jan 11;21(1):6. doi: 10.1186/s12959-023-00449-8. PMID: 36631860; PMCID: PMC9832773.\u003c/li\u003e\n\u003cli\u003eQi XS, Bai M, Yang ZP, Fan DM. Selection of a TIPS stent for management of portal hypertension in liver cirrhosis: an evidence-based review. 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Percutaneous transhepatic embolization of gastroesophageal varices combined with partial splenic embolization for the treatment of variceal bleeding and hypersplenism. Int J Clin Exp Med. 2015 Oct 15;8(10):19642-51. PMID: 26770628; PMCID: PMC4694528.\u003c/li\u003e\n\u003cli\u003eWang C, Yao J, Niu H, Yang C, Liu J, Bai Y, Ju S, Xiong B. Dynamic changes in liver function after transjugular intrahepatic portosystemic shunt in patients with cirrhosis. J Interv Med. 2022 Sep 14;5(4):207-212. doi: 10.1016/j.jimed.2022.09.001. PMID: 36532306; PMCID: PMC9751219.\u003c/li\u003e\n\u003cli\u003eLiu GP, Zhang MY, Xu R, Sun CJ. Acute liver failure and infarction complicating TIPS placement. Radiol Case Rep. 2019 May 10;14(7):876-879. doi: 10.1016/j.radcr.2019.04.013. PMID: 31193126; PMCID: PMC6517686.\u003c/li\u003e\n\u003cli\u003eAbraldes JG, Caraceni P, Ghabril M, Garcia-Tsao G. Update in the Treatment of the Complications of Cirrhosis. Clin Gastroenterol Hepatol. 2023 Jul;21(8):2100-2109. doi: 10.1016/j.cgh.2023.03.019. Epub 2023 Mar 25. PMID: 36972759; PMCID: PMC11097249.\u003c/li\u003e\n\u003cli\u003eJi K, Li X, Zhu H, Zhao S, Zhan P, Shi Y, Ye S, Xie B, Zhang Y, Yu P, Ren Z, Ding J, Han X, Li Z. A creatinine-based model for predicting recurrent bleeding after modified percutaneous transhepatic variceal embolization in patients with cirrhosis. J Interv Med. 2022 Mar 26;5(2):95-102. doi: 10.1016/j.jimed.2022.03.007. PMID: 35936666; PMCID: PMC9348999.\u003c/li\u003e\n\u003cli\u003eWang HL, Lu WJ, Zhang YL, Nie CH, Zhou TY, Zhou GH, Zhu TY, Wang BQ, Chen SQ, Yu ZN, Jing L, Sun JH. Comparison of Transjugular Intrahepatic Portosystemic Shunt in the Treatment of Cirrhosis With or Without Portal Vein Thrombosis: A Retrospective Study. Front Med (Lausanne). 2021 Oct 4;8:737984. doi: 10.3389/fmed.2021.737984. PMID: 34671621; PMCID: PMC8523019.\u003c/li\u003e\n\u003cli\u003eFriis KH, Thomsen KL, Laleman W, Montagnese S, Vilstrup H, Lauridsen MM. Post-Transjugular Intrahepatic Portosystemic Shunt (TIPS) Hepatic Encephalopathy-A Review of the Past Decade\u0026apos;s Literature Focusing on Incidence, Risk Factors, and Prophylaxis. J Clin Med. 2023 Dec 19;13(1):14. doi: 10.3390/jcm13010014. PMID: 38202028; PMCID: PMC10779844.\u003c/li\u003e\n\u003cli\u003eXia Y, Tie J, Wang G, Zhuge Y, Wu H, Xue H, Xu J, Zhang F, Zhao L, Huang G, Zhang M, Wei B, Li P, Wu W, Chen C, Tang C, Zhang C. Individualized portal pressure gradient threshold based on liver function categories in preventing rebleeding after TIPS. Hepatol Int. 2023 Aug;17(4):967-978. doi: 10.1007/s12072-023-10489-x. Epub 2023 Feb 17. PMID: 36807252; PMCID: PMC10386972.\u003c/li\u003e\n\u003cli\u003ePraktiknjo M, Abu-Omar J, Chang J, Thomas D, Jansen C, Kupczyk P, Schepis F, Garcia-Pagan JC, Merli M, Meyer C, Strassburg CP, Pieper CC, Trebicka J. Controlled underdilation using novel VIATORR\u0026reg; controlled expansion stents improves survival after transjugular intrahepatic portosystemic shunt implantation. JHEP Rep. 2021 Mar 3;3(3):100264. doi: 10.1016/j.jhepr.2021.100264. PMID: 34013182; PMCID: PMC8113713.\u003c/li\u003e\n\u003cli\u003eRaissi D, Yu Q, Nisiewicz M, Krohmer S. Parallel transjugular intrahepatic portosystemic shunt with Viatorr\u0026reg; stents for primary TIPS insufficiency: Case series and review of literature. World J Hepatol. 2019 Feb 27;11(2):217-225. doi: 10.4254/wjh.v11.i2.217. PMID: 30820271; PMCID: PMC6393714.\u003c/li\u003e\n\u003cli\u003eLi W, Liu M, Guan S, Ding P, Yuan J, Zhao Y, Li P, Ma F, Xue H. Comparison of outcomes for transjugular intrahepatic portosystemic shunt creation: Viatorr versus Fluency versus a bare stent/Fluency stent combination. CVIR Endovasc. 2024 Oct 18;7(1):76. doi: 10.1186/s42155-024-00489-9. PMID: 39422844; PMCID: PMC11489360.\u003c/li\u003e\n\u003cli\u003eAlbillos A, Ba\u0026ntilde;ares R, Gonz\u0026aacute;lez M, Catalina MV, Molinero LM. A meta-analysis of transjugular intrahepatic portosystemic shunt versus paracentesis for refractory ascites. J Hepatol. 2005 Dec;43(6):990-6. doi: 10.1016/j.jhep.2005.06.005. Epub 2005 Jul 5. PMID: 16139922.\u003c/li\u003e\n\u003cli\u003eGarc\u0026iacute;a-Pag\u0026aacute;n JC, Caca K, Bureau C, Laleman W, Appenrodt B, Luca A, Abraldes JG, Nevens F, Vinel JP, M\u0026ouml;ssner J, Bosch J; Early TIPS (Transjugular Intrahepatic Portosystemic Shunt) Cooperative Study Group. Early use of TIPS in patients with cirrhosis and variceal bleeding. N Engl J Med. 2010 Jun 24;362(25):2370-9. doi: 10.1056/NEJMoa0910102. PMID: 20573925.\u003c/li\u003e\n\u003cli\u003eHu XG, Dai JJ, Lu J, Li G, Wang JM, Deng Y, Feng R, Lu KP. Efficacy of transjugular intrahepatic portosystemic shunts in treating cirrhotic esophageal-gastric variceal bleeding. World J Gastrointest Surg. 2024 Feb 27;16(2):471-480. doi: 10.4240/wjgs.v16.i2.471. PMID: 38463371; PMCID: PMC10921195.\u003c/li\u003e\n\u003cli\u003eBoike JR, Thornburg BG, Asrani SK, Fallon MB, Fortune BE, Izzy MJ, Verna EC, Abraldes JG, Allegretti AS, Bajaj JS, Biggins SW, Darcy MD, Farr MA, Farsad K, Garcia-Tsao G, Hall SA, Jadlowiec CC, Krowka MJ, Laberge J, Lee EW, Mulligan DC, Nadim MK, Northup PG, Salem R, Shatzel JJ, Shaw CJ, Simonetto DA, Susman J, Kolli KP, VanWagner LB; Advancing Liver Therapeutic Approaches (ALTA) Consortium. North American Practice-Based Recommendations for Transjugular Intrahepatic Portosystemic Shunts in Portal Hypertension. Clin Gastroenterol Hepatol. 2022 Aug;20(8):1636-1662.e36. doi: 10.1016/j.cgh.2021.07.018. Epub 2021 Jul 15. PMID: 34274511; PMCID: PMC8760361.\u003c/li\u003e\n\u003cli\u003eLi GQ, Yang B, Liu J, Wang GC, Yuan HP, Zhao JR, Liu JY, Li XP, Zhang CQ. Hepatic venous pressure gradient is a useful predictor in guiding treatment on prevention of variceal rebleeding in cirrhosis. Int J Clin Exp Med. 2015 Oct 15;8(10):19709-16. PMID: 26770635; PMCID: PMC4694535.\u003c/li\u003e\n\u003cli\u003eSchultz G, Naas M, Webb J. Use of Partial Splenic Embolization Following a Transjugular Intrahepatic Portosystemic Shunt to Reduce Persistent Portal Hypertension Sequelae. Cureus. 2025 Aug 7;17(8):e89540. doi: 10.7759/cureus.89540. PMID: 40918905; PMCID: PMC12413769.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 4 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Transjugular Intrahepatic Portosystemic Shunt (TIPS), Percutaneous Transhepatic Gastric Variceal Embolization (PTVE), Esophageal-gastric variceal bleeding (EGVB), portal hypertension (PH), Rural areas","lastPublishedDoi":"10.21203/rs.3.rs-8143939/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8143939/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eEsophageal-gastric variceal bleeding (EGVB) secondary to portal hypertension (PH) poses a greater therapeutic challenge in rural China. Patients often present with more severe conditions, including a high prevalence of portal vein thrombosis, tumor thrombi, and cavernous transformation of the portal vein (CTPV), making conventional treatments less effective.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThis retrospective cohort study analyzed data from EGVB patients in rural Eastern China (Qingdao) who underwent interventional therapy between January 2021 and December 2024.Patients were divided into a Transjugular Intrahepatic Portosystemic Shunt (TIPS) group and a Percutaneous Transhepatic Gastric Variceal Embolization (PTVE) group. The primary outcomes were overall survival (OS), rebleeding intervals, and the incidence of hepatic encephalopathy (HE).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe median OS was significantly longer in the TIPS group compared to the PTVE group (23.0 months vs. 4.5 months). The rebleeding interval was also significantly longer in the TIPS group. Hepatic encephalopathy occurred exclusively in the TIPS group, with a two-year cumulative incidence of 28.17%. The two-year stent dysfunction rate in the TIPS group was 8.5%.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eFor eligible EGVB patients in rural China, TIPS is significantly superior to PTVE in improving long-term survival and preventing rebleeding. Therefore, TIPS should be considered the preferred treatment strategy, although careful monitoring and management of hepatic encephalopathy are essential.\u003c/p\u003e","manuscriptTitle":"Transjugular Intrahepatic Portosystemic Shunt versus Percutaneous Transhepatic Variceal Embolization for Esophageal-Gastric Variceal Bleeding in Rural China: A Retrospective Cohort Study Focusing on Survival and Rebleeding","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-08 07:14:04","doi":"10.21203/rs.3.rs-8143939/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2356aa8e-55dd-4e74-937a-ced8d27250a0","owner":[],"postedDate":"December 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-02-13T22:23:28+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-08 07:14:04","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8143939","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8143939","identity":"rs-8143939","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}