Improved survival in patients with refractory variceal bleeding treated with esophageal stents: A multicenter cohort study

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Background and Aims Tamponade is a bridge therapy for refractory variceal bleeding. This study compared esophageal stents (ES) and balloon tamponade (BT) in terms of early bleeding control and mortality. Methods We analyzed a cohort of patients with cirrhosis treated with tamponade in nine French hospitals between 2002 and 2023. The primary outcome was six-week mortality. Multivariable analyses included Cox with time-dependent covariates and logistic regression models, adjusted for MELD score, rescue TIPS (rTIPS), and inverse probability of treatment weighting (IPTW) for ES. Results Sixty-three patients (87.3% male; mean age 55 years; 73.0% Child-Pugh C) were included. ES was used in 30 patients, BT in 33, and rTIPS subsequently in 20. Endoscopic control was attempted in 66.1% of cases. Adverse events were more frequent with ES (56.7% vs. 27.3%, p=0.018), mostly stent migrations without clinical consequence, but less severe than with BT (two esophageal ruptures). Mortality was 42.9% (n=27) at day five and 55.5% (n=35) at six weeks. Univariable analysis revealed lower mortality with ES than with BT (20.0% vs. 63.6% on day five and 36.7% vs. 72.7% on week six, p=0.0015) and with rTIPS (10.0% vs. 58.1% on day five and 25.5% vs. 67.5% on week six, p=0.0009). IPTW-adjusted and IPTW-weighted time-dependent Cox and logistic models confirmed decreased six-week mortality (HR=0.26, p=0.0078) and better five-day bleeding control (OR=6.1, p=0.020) with ES. Conclusions In patients cirrhosis-related refractory variceal bleeding, esophageal stent was associated with significantly better early bleeding control and reduced mortality at both day five and week six compared to balloon tamponade. Prospective studies are warranted to confirm these findings. Impact and implication Tamponade devices are critical in the management of refractory variceal bleeding, with balloon probes being the only option until the early 2000s. More recently, self-expanding esophageal stents have been recommended, although their superiority over balloons in terms of survival has not been demonstrated. Our multicenter cohort study, using propensity score analysis, found that esophageal stents provided superior bleeding control at day five and survival benefit at week six, regardless of severity of liver failure or use of rescue TIPS. These findings highlight esophageal stents as the optimal tamponade device, although they may not obviate the need for prompt rescue TIPS placement.

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