Pre-emptive TIPS with 8-mm stents reduces hepatic encephalopathy without compromising efficacy in acute variceal bleeding
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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.
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Le contrôle bibliographique ouvert
DOI retrouvé dans Crossref DOI retrouvé ; titre concordant.
- Titre Crossref
- Pre-emptive TIPS with 8-mm stents reduces hepatic encephalopathy without compromising efficacy in acute variceal bleeding
- Date Crossref
- 01/11/2025
- Éditeur
- Elsevier BV
- Type
- journal-article
Ce recoupement confirme des métadonnées liées au DOI. Il ne confirme ni la méthode ni les conclusions de l’étude, et il ne compte pas comme une seconde source scientifique indépendante.
Où se fait cette recherche
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National Clinical Research Center for Digestive Diseases pays non établi dans la noticeÉtablissement de santé
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Xijing Hospital pays non établi dans la noticeÉtablissement de santé
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Air Force Medical University pays non établi dans la noticeUniversité ou école supérieure
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Xi'an Medical University Department of Gastroenterology pays non établi dans la noticeUniversité ou école supérieure
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Northwest University Department of Liver Diseases and Interventional Radiology pays non établi dans la noticeUniversité ou école supérieure
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Nanfang Hospital pays non établi dans la noticeÉtablissement de santé
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Southern Medical University Department of Interventional Radiology pays non établi dans la noticeUniversité ou école supérieure
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Nanchang University Department of Gastroenterology pays non établi dans la noticeUniversité ou école supérieure
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Soochow University Department of Interventional Radiology pays non établi dans la noticeUniversité ou école supérieure
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First Affiliated Hospital of Soochow University pays non établi dans la noticeÉtablissement de santé
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First Affiliated Hospital of Nanchang University pays non établi dans la noticeÉtablissement de santé
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Sun Yat-sen University Department of Interventional Radiology pays non établi dans la noticeUniversité ou école supérieure
National Clinical Research Center for Digestive Diseases, Xijing Hospital et Air Force Medical University, avec 9 autres affiliations.
Une affiliation ne permet pas de déduire la nationalité d’un auteur.