Three-Dimensional Portal Vein Geometry Predicts Post-TIPS -Hepatic Encephalopathy and Variceal Rebleeding: A Multicenter Study.

BACKGROUND AND AIMS: Post-TIPS overt hepatic encephalopathy (OHE) and variceal rebleeding (VRB) remain serious complications with limited predictive tools. This study investigates whether the inherent preoperative three-dimensional portal venous geometry (3D-PVG) serves as an independent prognostic biomarker for 1year OHE and VRB in patients undergoing transjugular intrahepatic portosystemic shunt (TIPS).

METHODS

In this multicenter retrospective study, 579 cirrhotic patients undergoing successful TIPS were enrolled. We extracted 3D-PVG features from routine computed tomography angiography (CTA) images before TIPS, quantifying bifurcation angles ('Near') and vessel segment tortuosity ('Far'). Cox regression identified predictors for 1-year OHE and VRB. Model performance was evaluated using Harrell's C-index, comparing clinical models against integrated clinical-geometric models (3D-CGM).

RESULTS

For 1-year OHE, increased age (HR 1.458, p < 0.001), higher BUN (HR 1.171, p = 0.019), and extremely flat bifurcations (near_bin_87: 172°-174°; HR 1.104, p = 0.039) were independent risk factors. For 1-year VRB, first bleeding (HR 2.347, p = 0.027), elevated Cr (HR 1.244, p = 0.012), relatively flat bifurcations (near_bin_74: 146°-148°; HR 1.432, p = 0.001), and very straight vessel segments (far_bin_2: 2°-4°; HR 1.467, p = 0.013) were risk factors, while use of covered stents (HR 0.197, p = 0.013) and gently curved vessel segments (far_bin_27: 52°-54°; HR 0.262, p = 0.018) were protective factors. Integrating 3D-PVG features significantly improved predictive performance: the 3D-CGM achieved C-indices of 0.801 for OHE and 0.792 for VRB, surpassing clinical models (0.715 and 0.686, respectively).

CONCLUSION

The inherent portal venous geometry may serve as an independent imaging biomarker for post-TIPS outcomes. The 3D-CGM markedly enhances risk prediction, providing a non-invasive approach for prognosis assessment in portal hypertension.