Hepatic Venous Pressure Gradient (HVPG)-Guided Secondary Prophylaxis Of Variceal Hemorrhage

Objective:In this study, the different therapeutic options were assigned to patients according to the level of HVPG values; the aim of the study was to determine whether this prophylactic treatment strategy was effective in preventing variceal rebleeding.Materials and Method:109cirrhotic patients with esophageal variceal bleeding were enrolled from Shandong Provincial Hospital from October2010to January2014. They were divided into two groups:55patients (endoscopic variceal ligation (EVL)+β-blocker group) were treated with EVL and β-blocker;54patients (HVPG-guided group) were treated with EVL and β-blocker if HVPG≤16mmHg (low-HVPG), with percutaneous transhepatic variceal embolization (PTVE) if HVPG>16mmHg and≤20mmHg (medium-HVPG), or with transjugular intrahepatic portosystemic s hunt (TIPS) if HVPG>20mmHg (high-HVPG). Patients were followed up for rebleeding and mortality. Frequency variables were compared using the Pearson’s chi-squared test, or Fisher’s exact test when necessary. Quantitative variables were analyzed using the Student’s t-test. The cumulative risks of rebleeding and mortality were evaluated by the Kaplan-Meier method; comparisons between different groups were made with the log-rank test. The Statistical Package for Social Sciences (SPSS) version19.0was used.Results:The mean follow-up period was17.0months.The incidence of rebleeding was higher in the EVL+β-blocker group than HVPG-guided group (25.5%vs.9.3%,P=0.026). EVL-treated patients with higher HVPG had higher3-year probability of rebleeding (12.5%vs46.4%vs64.9%,χ2=11.551,P=0.003).while there was no significant difference in survival among three groups(96.6%vs85.7%vs90.9%,χ2=2.638, P=0.267). The incidence of rebleeding was only7.7%in the PTVE-treated group, whilst it was35.7%in EVL+β blocker-treated group(medium-HVPG). It exhibited a decreasing trend but no statistically significant difference. The incidence of rebleeding was only7.7%in the TIPS-treated group, whilst it was45.5%in the EVL+β blocker-treated group(high-HVPG).It exhibited a decreasing trend but no statistically significant difference.Conclusion:The HVPG value is an important factor in predicting the outcome of EVL+β blocker-treated patients, and patients with high HVPG values have a high risk of rebleeding. In patients with high HVPG values, PTVE or TIPS may be a favorable alternative to the combination of EVL and β-blocker. HVPG measurement is useful for making decisions to select EVL+β blocker, PTVE or TIPS in secondary prophylaxis. HVPG-guided treatment is feasible and effective in preventing esophageal varices rebleeding.