 Since the year 2000, a new polytetrafluoroethylene covered stent has highly improved TIPS patency, thus inducing a remarkable reduction of rebleeding incidence. Some authors, however, suggest that the maintenance of the shunt patency may involve an increased risk of hepatic encephalopathy, although the data in the present literature are limited and controversial. The only randomized controlled study3 available, in fact, reports a lower incidence of hepatic encephalopathy in those patients treated with covered stents as compared with those treated with conventional metallic stents. In our preliminary experience,4 instead, a similar incidence of hepatic encephalopathy was noted in both groups. In addition, in the group of patients treated by covered stents, a higher number of cases with persistent and intractable hepatic encephalopathy requiring shunt reduction was recorded.5 Post-TIPS hepatic encephalopathy incidence increases with the decrease of post-procedure portal pressure which depends on the caliber of the stent used to create the anastomosis. This might suggest the use of covered stents with a smaller diameter aimed at reducing the risk of hepatic encephalopathy. Coated stents with different diameters are presently commercially available, but clinical studies on the assessment of the best stent diameter for a better clinical efficacy, a reduced number of complications, and an effective portal pressure reduction essential in the treatment of those pathologies in which TIPS is indicated still do not exist. 