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

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.