The transjugular intrahepatic portosystemic shunt: Smaller stent diameters are required to optimize pressure response.

Background and aims: The present treatment goal of the transjugular intrahepatic portosystemic shunt (TIPS) is a portosystemic pressure gradient of ≤12 mmHg or its reduction by >50%. This study relates the stent diameter to the reduction of the pressure gradient and attempts to predict the appropriate stent diameter necessary to reach the treatment goal. Methods: Pressure response, super response, and poor response were investigated in 208 de-novo TIPS patients and defined as post-TIPS gradients between >6 and 12 mmHg, ≤6 mmHg, or not reaching the goal (>12 mmHg, reduction <50%), respectively. Pressures were related to the smallest stent diameters measured by planimetry of the radiographic image. Results: Responders (65%), super responders (26%), or poor responders (9%) had comparable stent diameters of 7.2 ± 1.0 mm, but different post-TIPS gradients (9.7 ± 1.9 mmHg, 4.5 ± 1.5 mmHg, and 14.2 ± 1.4 mmHg, Conclusion: Most patients reached the treatment goal with stent diameters of <8 mm. Overtreatment (super response, gradient ≤6 mmHg) can be prevented by stent diameters as small as 6 mm. The individual response was not related to the stent diameter and not predictable. Cardiac dysfunction may play an important role by its effect on the right atrial (preload) and portal pressure (afterload).