Pre-emptive TIPS with 8-mm stents reduces hepatic encephalopathy without compromising efficacy in acute variceal bleeding

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.