- •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.
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.
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.
To read this article in full you will need to make a payment
Purchase one-time access:Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
One-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:Subscribe to Journal of Hepatology
Already a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
Author names in bold designate shared co-first authorship
- Developing consensus in portal hypertension.J Hepatol. 1996; 25: 390-394
- Updating consensus in portal hypertension: report of the Baveno III Consensus Workshop on definitions, methodology and therapeutic strategies in portal hypertension.J Hepatol. 2000; 33: 846-852
- The role of transjugular intrahepatic portosystemic shunt in the management of portal hypertension.Hepatology. 2005; 41: 386-400
- Evolving consensus in portal hypertension: report of the Baveno IV Consensus Workshop on methodology of diagnosis and therapy in portal hypertension.J Hepatol. 2005; 43: 167-176
- The role of transjugular intrahepatic portosystemic shunt (TIPS) in the management of portal hypertension: update 2009.Hepatology. 2010; 51: 306
- Revising consensus in portal hypertension: report of the Baveno V consensus workshop on methodology of diagnosis and therapy in portal hypertension.J Hepatol. 2010; 53: 762-768
- Expanding consensus in portal hypertension: Report of the Baveno VI Consensus Workshop: Stratifying risk and individualizing care for portal hypertension.J Hepatol. 2015; 63: 743-752
- New non-operative treatment for variceal haemorrhage.Lancet. 1989; 2: 153
- Assessment of liver function in patients with hepatocellular carcinoma: a new evidence-based approach-the ALBI grade.J Clin Oncol. 2015; 33: 550-558
- TIPS: 25 years later.J Hepatol. 2013; 59: 1081-1093
- Limiting diameter in transjugular intrahepatic portosystemic shunt.Radiology. 1994; 193: 130
- Transjugular intrahepatic portosystemic shunt procedure: efficacy of 10-mm vs. 12-mm Wallstents.Radiology. 1996; 199: 658-664
- Polytetrafluoroethylene-covered stent grafts for TIPS procedure: 1-year patency and clinical results.Am J Gastroenterol. 2004; 99: 280-285
- Improved clinical outcome using polytetrafluoroethylene-coated stents for TIPS: results of a randomized study.Gastroenterology. 2004; 126: 469-475
- Patency of stents covered with polytetrafluoroethylene in patients treated by transjugular intrahepatic portosystemic shunts: long-term results of a randomized multicentre study.Liver Int. 2007; 27: 742-747
- Early use of TIPS in patients with cirrhosis and variceal bleeding.N Engl J Med. 2010; 362: 2370-2379
- Covered transjugular intrahepatic portosystemic shunt vs. endoscopic therapy+beta-blocker for prevention of variceal rebleeding.Hepatology. 2016; 63: 581-589
- Predictors of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt in cirrhotic patients: a systematic review.J Gastroenterol Hepatol. 2011; 26: 943-951
- Patency and clinical outcomes of transjugular intrahepatic portosystemic shunt with polytetrafluoroethylene-covered stents vs. bare stents: a meta-analysis.J Gastroenterol Hepatol. 2010; 25: 1718-1725
- Clinical efficacy of transjugular intrahepatic portosystemic shunt created with covered stents with different diameters: results of a randomized controlled trial.J Hepatol. 2010; 53: 267-272
- Prevention of rebleeding from esophageal varices in patients with cirrhosis receiving small-diameter stents vs. hemodynamically controlled medical therapy.Gastroenterology. 2015; 149: 660-668
- Shunting branch of portal vein and stent position predict survival after transjugular intrahepatic portosystemic shunt.World J Gastroenterol. 2014; 20: 774-785
- Emergency TIPS in a Child-Pugh B patient: When does the window of opportunity open and close?.J Hepatol. 2017; 66: 442-450
- Consensus conference on TIPS management: Techniques, indications, contraindications.Dig Liver Dis. 2017; 49: 121-137
- Human body surface area database and estimation formula.Burns. 2010; 36: 616-629
- Transjugular intrahepatic portosystemic shunt for portal vein thrombosis with symptomatic portal hypertension in liver cirrhosis.J Hepatol. 2011; 54: 78-88
- Implementation and experience of a web-based allocation system with Pocock and Simon's minimization methods.Contemp Clin Trials. 2010; 31: 510-513
- Transjugular intrahepatic portosystemic shunt for portal vein thrombosis with variceal bleeding in liver cirrhosis: outcomes and predictors in a prospective cohort study.Liver Int. 2016; 36: 667-676
- Shunt dysfunction: is it suitable as the primary end point in transjugular intrahepatic portosystemic shunt trials?.J Hepatol. 2015; 62: 245-247
- The CLIF Consortium Acute Decompensation score (CLIF-C ADs) for prognosis of hospitalised cirrhotic patients without acute-on-chronic liver failure.J Hepatol. 2015; 62: 831-840
- Hepatic encephalopathy in chronic liver disease: 2014 Practice Guideline by the American Association for the Study of Liver Diseases and the European Association for the Study of the Liver.Hepatology. 2014; 60: 715-735
- Covered vs. uncovered stents for transjugular intrahepatic portosystemic shunt: a randomized controlled trial.J Hepatol. 2014; 60: 962-968
- Emerging issues in the use of transjugular intrahepatic portosystemic shunt (TIPS) for management of portal hypertension: time to update the guidelines?.Dig Liver Dis. 2010; 42: 462-467
- Causes of TIPS dysfunction.AJR Am J Roentgenol. 2008; 191: 1751-1757
- Endovascular management of refractory hepatic encephalopathy complication of transjugular intrahepatic portosystemic shunt (TIPS): comprehensive review and clinical practice algorithm.Cardiovasc Intervent Radiol. 2016; 39: 170-182
- Timing affects measurement of portal pressure gradient after placement of transjugular intrahepatic portosystemic shunts in patients with portal hypertension.Gastroenterology. 2017; 152: 1358-1365
- Definition and nomenclature of hepatic encephalopathy.J Clin Exp Hepatol. 2015; 5: S37-S41
- Successful reversal of hepatic encephalopathy with intentional occlusion of transjugular intrahepatic portosystemic shunts.J Vasc Interv Radiol. 1995; 6: 917-921
- Transjugular intrahepatic portosystemic stent shunt (TIPSS) modification in the management of post-TIPSS refractory hepatic encephalopathy.Gut. 2006; 55: 1617-1623
- Incidence, natural history, and risk factors of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt with polytetrafluoroethylene-covered stent grafts.Am J Gastroenterol. 2008; 103: 2738-2746
- Management of transjugular intrahepatic portosystemic shunt (TIPS)-associated refractory hepatic encephalopathy by shunt reduction using the parallel technique: outcomes of a retrospective case series.Cardiovasc Intervent Radiol. 2011; 34: 92-99
- Current diagnosis and management of post-transjugular intrahepatic portosystemic shunt refractory hepatic encephalopathy.Liver Int. 2015; 35: 2487-2494
Published online: May 12, 2017
Accepted: May 3, 2017
Received in revised form: April 20, 2017
Received: March 4, 2017
© 2017 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.