Pre-emptive TIPS with 8-mm stents reduces hepatic encephalopathy without compromising efficacy in acute variceal bleeding
Year: 2025
Type: article
Study design: Observational Study
Abstract: Background & Aims Pre-emptive transjugular intrahepatic portosystemic shunt (TIPS) improves outcomes in high-risk acute variceal bleeding but its use is limited by hepatic encephalopathy (HE). While stent diameter and post-TIPS portacaval pressure gradient (PPG) targets may influence HE risk, evidence-based standards are lacking. This study aimed to compare 8-mm vs. 10-mm diameter stents and evaluate PPG thresholds to balance HE risk and therapeutic efficacy. Methods In this multicenter observational study, 470 patients with cirrhosis and acute variceal bleeding receiving pre-emptive TIPS (8-mm: n=384; 10-mm: n=86) were analyzed. Competing risks regression and restricted cubic splines were used to assess associations between stent diameter, PPG, and clinical outcomes. Results At 1 year, 8-mm stents reduced overt HE incidence (28.9% vs. 45.4%; subdistribution hazard ratio [sHR] 0.57, 95% CI 0.40–0.82) and further decompensation (40.4% vs. 52.3%; sHR 0.68, 95% CI 0.48–0.95) compared to 10-mm stents, without increasing the risk of further bleeding (12.0% vs. 9.3%; p = 0.471) or mortality (13.3% vs. 14.0%; p = 0.813). Non-linear analysis identified a PPG range of 7–13 mmHg associated with minimized overt HE risks (sHR 1.43 for PPG <7 vs. 7–13 mmHg; 95% CI 1.01–2.01) and portal hypertensive complications (sHR 2.76 for PPG >13 vs. 7–13 mmHg; 95% CI 2.69–9.39). A significantly greater proportion of patients in the 8-mm group attained the optimal 7–13 mmHg target range compared to the 10-mm group (71.1% vs. 55.8%, p <0.001). Conclusions Pre-emptive TIPS with 8-mm stents reduces HE and further decompensation without compromising efficacy. Immediate post-TIPS PPG measurements may aid intraprocedural decision-making, with a 7–13 mmHg range serving as a pragmatic guide for initial stent calibration in high-risk acute variceal bleeding. Impact and implications This multicenter study of 470 patients with cirrhosis and acute variceal bleeding shows that pre-emptive transjugular intrahepatic portosystemic shunt (TIPS) placement using 8-mm stents reduces the 1-year incidence of overt hepatic encephalopathy by 43% compared to 10-mm stents, while maintaining similar efficacy in preventing rebleeding. Non-linear analysis identified a post-TIPS portacaval pressure gradient (PPG) range of 7–13 mmHg as an optimal target, minimizing risks of both overt hepatic encephalopathy and portal hypertensive complications. A significantly higher proportion of patients achieved this PPG range with 8-mm stents. These results address a key dilemma in high-risk AVB management, demonstrating that 8-mm stents balance encephalopathy prevention with effective portal decompression. The 7–13 mmHg PPG range provides a practical intraprocedural guide for individualized TIPS calibration, helping interventional radiologists optimize shunt diameter selection.
Source: JHEP Reports
Authors: Yong Lv, Junjun Ye, Wei Bai, Yan Zhao, Jianbo Zhao, Xuan Zhu, Mingsheng Huang, Hui Xue, Yuzheng Zhuge, Chunqing Zhang, Pengxu Ding, Xiaoli Zhu, Weixin Ren, Tao Yang, Jun Wang, Wenguang Zhang, Kai Li, Zhengyu Wang, Bohan Luo, Na Zhang, Zhiping Yang, Wengang Guo, Dongdong Xia, Huahong Xie, Yanglin Pan, Yongzhan Nie, Zhanxin Yin, Daiming Fan, Guohong Han
Institutions: National Clinical Research Center for Digestive Diseases, Xijing Hospital, Air Force Medical University, Xi'an Medical University, Northwest University, Nanfang Hospital, Southern Medical University, First Affiliated Hospital of Soochow University, First Affiliated Hospital of Nanchang University, Third Affiliated Hospital of Sun Yat-sen University, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an Jiaotong University, Nanjing Drum Tower Hospital, Nanjing University, Shandong University, Shandong Provincial Hospital, First Affiliated Hospital of Zhengzhou University, Xinjiang Medical University, First Affiliated Hospital of Xinjiang Medical University, Guizhou University
Language: English
Subfield: Hepatology
Field: Medicine
Domain: Health Sciences
Open Access status: gold
Estimated APC paid: $4,110
Funders: Shandong University, National Natural Science Foundation of China, Guizhou University, Northwest University, Zhengzhou University, Nanchang University, Xinjiang Medical University, Fourth Military Medical University, Soochow University, Nanjing University, Southern Medical University, Nanfang Hospital, Xi'an Medical University, National Key Research and Development Program of China
OpenAlex ID: W4415696167