Published online Sep 28, 2026. doi: 10.5528/wjtm.124020
Revised: July 11, 2026
Accepted: July 28, 2026
Published online: September 28, 2026
Processing time: 91 Days and 17.5 Hours
Hepatic encephalopathy (HE) remains a major complication of transjugular intrahepatic portosystemic shunt (TIPS) creation, occurring in approximately 30% of patients despite the widespread adoption of polytetrafluoroethylene (PTFE)-covered stents. Stent diameter influences the volume of portal blood diverted to the systemic circulation and may thereby modulate the risk of post-procedural HE. Whether 6-mm covered stents can reduce encephalopathy without compromising hemodynamic efficacy or survival relative to the standard 8-mm configuration is uncertain.
To compare the efficacy and safety of 6-mm vs 8-mm covered stents in adults undergoing TIPS for cirrhotic portal hypertension.
A systematic review and meta-analysis was conducted in accordance with PRISMA 2020 guidance. MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched through the end of 2025. Studies comparing 6-mm and 8-mm PTFE-covered stents for TIPS creation in adults with cirrhotic portal hypertension were eligible. Risk of bias was assessed with RoB 2 for randomised trials and ROBINS-I for non-randomised studies. Pooled risk ratios (RR) and mean differences were estimated under a random-effects model. Certainty of evidence was rated with the Grading of Recommendations, Assessment, Development and Evaluations framework.
Five studies were included: One randomised controlled trial (Zhang et al) and four non-randomised cohort studies (Liu et al, Yan et al, Xia et al, Yao et al), enrolling a combined 2060 patients. The 6-mm stent was associated with a significant reduction in overall HE (RR = 0.56; 95%CI: 0.41-0.75; P = 0.0001; I² = 0%) and in overt HE (RR = 0.62; 95%CI: 0.41-0.93; P = 0.02; I² = 54%). Achievement of the target portal pressure gradient below 12 mmHg did not differ significantly between stent diameters (RR = 0.93; 95%CI: 0.83-1.03; P = 0.16; I² = 0%). Overall survival at 2 years (RR = 1.04; 95%CI: 0.96-1.13; P = 0.32), shunt dysfunction (RR = 0.97; 95%CI: 0.71-1.32; P = 0.83), and variceal rebleeding (RR = 1.28; 95%CI: 0.96-1.69; P = 0.09) were not significantly different.
A 6-mm effective shunt diameter was associated with a lower risk of HE after TIPS than an 8-mm diameter, without a detectable difference in survival, shunt patency, or portal decompression, and with a possible increase in variceal rebleeding. Because the certainty of evidence was low to very low and most data derived from non-randomised studies, these findings are hypothesis-generating and are not sufficient to recommend a preferred stent configuration; individualised consideration is required, particularly for patients at elevated baseline rebleeding risk.
Core Tip: This systematic review and meta-analysis of one randomised trial and four non-randomised studies compared 6-mm and 8-mm covered stents for transjugular intrahepatic portosystemic shunt. A 6-mm effective diameter was associated with a lower risk of hepatic encephalopathy, with no detectable difference in portal-pressure-gradient target achievement, survival or shunt dysfunction, and a possible increase in variceal rebleeding. Because the certainty of evidence was low to very low, these findings are hypothesis-generating and should not yet guide the choice of stent diameter in clinical practice.