Eight millimetre covered TIPS does not compromise shunt function but reduces hepatic encephalopathy in preventing variceal rebleeding

•Shunt patency and rebleeding rate were non-different between groups. •8 mm group showed lower spontaneous overt hepatic encephalopathy risk. •Liver function reserve was better in 8 mm stents group. Background & Aims Currently, there are no recommendations in guidelines concerning the preferred diameter of stents for transjugular intrahepatic portosystemic shunt (TIPS), owing to the lack of adequate evidence. We therefore compared 8 mm stents with 10 mm stents, to evaluate whether 8 mm stents would achieve similar shunt function, with less hepatic encephalopathy (HE) and better liver function. Methods Cirrhotic patients were randomly assigned to receive TIPS with an 8 mm or 10 mm covered stent to prevent variceal rebleeding. The primary endpoint was shunt dysfunction. All-cause rebleeding, orthotopic liver transplantation (OLT)-free survival, their composite endpoint, overt HE (overall and spontaneous) and liver function were designated as the secondary endpoints. Results From July 2012 to January 2014, 64 and 63 patients were allocated to the 8 mm and 10 mm groups, respectively. During a median follow-up of 27 months in both arms, dysfunction rates (16% vs. 16% at two years, p = 0.62), two-year rebleeding (16% vs. 17%, p = 0.65), OLT-free survival (95% vs. 86%, p = 0.37), and the composite endpoint (p = 0.62) were not statistically different between the groups. Despite a marginal decrease in overall overt HE, there were significantly fewer spontaneous overt HE incidents in the 8 mm group within two years (27% vs. 43%, p = 0.03), with a risk reduction of 47%. Notably, patients receiving 8 mm stents also developed less hepatic impairment. Conclusions TIPS with 8 mm covered stents showed similar shunt function to TIPS with 10 mm stents, but halved the risk of spontaneous overt HE and reduced hepatic impairment. Therefore, 8 mm TIPS stents should be preferred for the prevention of variceal rebleeding in cirrhotic patients. Lay summary: The optimal diameter for transjugular intrahepatic portosystemic shunt (TIPS) remained uncertain. This study showed that TIPS with 8 mm covered stents did not compromise shunt patency, or influence the efficacy of variceal rebleeding prevention compared to TIPS with 10 mm stents, but reduced the risk of spontaneous overt hepatic encephalopathy and the incidence of severe encephalopathy. Moreover, liver function reserve was also better in the 8 mm stents group, suggesting that 8 mm TIPS stents should be preferred for the prevention of variceal rebleeding in cirrhotic patients. Currently, there are no recommendations in guidelines concerning the preferred diameter of stents for transjugular intrahepatic portosystemic shunt (TIPS), owing to the lack of adequate evidence. We therefore compared 8 mm stents with 10 mm stents, to evaluate whether 8 mm stents would achieve similar shunt function, with less hepatic encephalopathy (HE) and better liver function. Cirrhotic patients were randomly assigned to receive TIPS with an 8 mm or 10 mm covered stent to prevent variceal rebleeding. The primary endpoint was shunt dysfunction. All-cause rebleeding, orthotopic liver transplantation (OLT)-free survival, their composite endpoint, overt HE (overall and spontaneous) and liver function were designated as the secondary endpoints. From July 2012 to January 2014, 64 and 63 patients were allocated to the 8 mm and 10 mm groups, respectively. During a median follow-up of 27 months in both arms, dysfunction rates (16% vs. 16% at two years, p = 0.62), two-year rebleeding (16% vs. 17%, p = 0.65), OLT-free survival (95% vs. 86%, p = 0.37), and the composite endpoint (p = 0.62) were not statistically different between the groups. Despite a marginal decrease in overall overt HE, there were significantly fewer spontaneous overt HE incidents in the 8 mm group within two years (27% vs. 43%, p = 0.03), with a risk reduction of 47%. Notably, patients receiving 8 mm stents also developed less hepatic impairment. TIPS with 8 mm covered stents showed similar shunt function to TIPS with 10 mm stents, but halved the risk of spontaneous overt HE and reduced hepatic impairment. Therefore, 8 mm TIPS stents should be preferred for the prevention of variceal rebleeding in cirrhotic patients.