ABSTRACT Aims Thrombocytopenia and antiangiogenic agents increase bleeding risk in hepatocellular carcinoma (HCC). We aimed to identify a baseline platelet threshold for bleeding risk stratification. Methods This single‐center retrospective cohort included 489 HCC patients treated with antiangiogenic agents from January 2018 to June 2022 without prophylactic platelet‐increasing interventions. Bleeding events were defined using International Society on Thrombosis and Hemostasis criteria. Fine and Gray competing‐risk models were used to explore platelet‐count cutoffs associated with bleeding. Associations were assessed with logistic regression and Chi‐square/Fisher's exact tests, adjusting for key confounders including high‐risk esophageal and gastric varices (EGV). Severe thrombocytopenia was defined as baseline platelets < 50 × 109/L. Results The bleeding rate was 11.0% (54/489). Baseline platelet counts were lower in patients with bleeding than in those without (median 116 × 109/L vs. 140 × 109/L; p = 0.015). Bleeding was more frequent with severe thrombocytopenia (< 50 × 109/L) than with platelet counts ≥ 50 × 109/L (22.9% [8/35] vs. 10.1% [46/454]; p = 0.021). Although platelet count < 50 × 109/L was associated with bleeding in univariable analyses, it was not independently predictive after multivariable adjustment; high‐risk EGV remained the dominant independent risk factor. Conclusion Baseline platelets < 50 × 109/L is a useful risk‐stratification marker (not an independent predictive biomarker) for bleeding during antiangiogenic therapy in HCC, and this threshold should be interpreted alongside variceal risk assessment, particularly in patients with high‐risk EGV.

INTRODUCTION:Hepatic encephalopathy (HE) is a major complication following transjugular intrahepatic portosystemic shunt (TIPS) placement, significantly affecting patients' quality of life and long-term prognosis. This study aims to compare the efficacy of underdilated TIPS versus standard TIPS in preventing variceal rebleeding in patients with cirrhosis and portal hypertension and to evaluate the incidence of post-procedural HE. METHODS AND ANALYSIS:This multicentre randomised controlled trial will be conducted across five Grade A tertiary hospitals in China. A total of 648 patients with portal hypertension-related oesophagogastric variceal bleeding undergoing TIPS will be enrolled and randomly assigned in a 1:1 ratio to either the experimental or control group. In the experimental group, underdilated TIPS will be performed using 6 mm balloon for stent expansion. In the control group, standard TIPS will be performed using progressive balloon dilation, starting at 8 mm and increasing stepwise as needed until the portosystemic pressure gradient is reduced to <12 mm Hg. The primary endpoint is the rebleeding rate over the entire follow-up period after TIPS. Secondary endpoints include the incidence of HE and liver function impairment. All statistical analyses will be performed using SPSS V.27.0 (IBM, Armonk, New York, USA), with a significance level set at p<0.05. ETHICS AND DISSEMINATION:The study protocol (V.2, 1 July 2025) has been approved by the Medical Ethics Committee of the First Affiliated Hospital of Air Force Medical University (Approval No.: KY20252233-F-2). Written informed consent will be obtained from all participants prior to enrolment. Findings will be presented at academic conferences and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER:ChiCTR2500110490; NCT07253389.

BACKGROUND:This real-world study aimed to evaluate and compare the efficacy and safety of two treatment strategies for advanced hepatocellular carcinoma (HCC): transarterial chemoembolisation (TACE) combined with camrelizumab and apatinib versus camrelizumab and apatinib alone. METHODS:In this nationwide, multi-centre retrospective cohort study, data were collected on patients with advanced HCC who received either TACE combined with camrelizumab and apatinib (T-C-A) or camrelizumab and apatinib alone (C-A) between January 2018 and December 2022. To reduce potential bias, stabilised inverse probability of treatment weighting (sIPTW) was applied. The primary outcome was overall survival (OS), while secondary outcomes included progression-free survival (PFS), objective response rate (ORR) based on RECIST v1.1 criteria, and safety. RESULTS:A total of 252 HCC patients were included (T-C-A group, n = 183; C-A group, n = 69). Among them, 210 were males and 42 were females, with a median age of 54 years. After sIPTW, the median OS was significantly longer in the T-C-A group compared to the C-A group (24.2 months [95% CI: 21.4-33.4] vs. 15.2 months [95% CI: 9.8-21.0]; p < 0.001). The T-C-A group also demonstrated a significantly improved median PFS of 10.1 months [95% CI: 8.8-12.2], compared to 4.9 months [95% CI: 4.0-12.5] in the C-A group (p < 0.001). Further, the ORR was higher in the T-C-A group. Grade 3/4 adverse events were reported in 12.0% of patients in the T-C-A group and 14.5% in the C-A group. CONCLUSION:The combination of TACE with camrelizumab and apatinib suggests potential survival advantages for patients with advanced HCC while maintaining an acceptable safety profile.(Study series number CHANCE 2311).

BACKGROUND The effect of post-transjugular intrahepatic portosystemic shunt (TIPS) rebleeding on liver-related mortality remains uninvestigated. AIM To investigate the relationship between post-TIPS rebleeding and liver-related mortality in patients with cirrhosis and to conduct subgroup analyses based on liver function. METHODS This study included 1782 patients who underwent covered TIPS at seven medical centers to prevent rebleeding. The primary endpoints were liver-related death and all-cause rebleeding. Propensity score matching, adjusted survival curves, and competing risk analyses based on liver transplantation and non-liver death were performed to ensure the robustness of the results. RESULTS During a median follow-up period of 32.25 months, 346 patients (19.4%) developed post-TIPS rebleeding, and 429 (24.1%) died from liver-related causes. Chronic HBV infection was the predominant cirrhosis etiology. Multivariable analysis identified older age, higher Child-Pugh and model for end-stage liver disease-Na scores, and post-TIPS rebleeding as independent predictive factors for liver-related mortality. Liver-related mortality increased by approximately 49.4% in the rebleeding group compared with the no-bleeding group. These findings remained consistent after propensity score matching, survival curve adjustment, and competing risk assessment. Similar findings were observed across different liver function subgroups. CONCLUSION Post-TIPS rebleeding was significantly associated with higher mortality in patients with cirrhosis and variceal bleeding irrespective of liver function category.

Background:This study aimed to assess the clinical outcomes of transarterial chemoembolization (TACE) with immune checkpoint inhibitors (ICIs) plus vascular endothelial growth factor (VEGF) inhibitors or tyrosine kinase inhibitors (TKIs) (combination therapy) versus TACE monotherapy as a first-line treatment for intermediate-stage hepatocellular carcinoma (HCC). Methods:This nationwide, retrospective cohort study employed a target trial emulation framework with a cloning-censoring-weighting approach. Patients with intermediate-stage HCC receiving either combination therapy or TACE monotherapy between January 2018 and December 2022 in China were included. Co-primary outcomes were overall survival (OS) and progression-free survival (PFS) per modified Response Evaluation Criteria in Solid Tumors (mRECIST), assessed using restricted mean survival time (RMST). Hazard ratio (HR) was additionally estimated using Cox proportional hazards models for reference. For both RMST and HR, 95% CIs were obtained by bootstrapping. Secondary outcomes included PFS per RECIST 1.1, objective response rate (ORR) per both mRECIST and RECIST 1.1, and safety. This study is registered at ClinicalTrials.gov (NCT05332496). Findings:A total of 941 patients were included in the study, with 308 (32.7%) receiving combination therapy, and 633 (67.3%) receiving TACE monotherapy. Median OS was 32.9 with combination therapy versus 23.0 months with TACE monotherapy, with an RMST difference of 9.2 months (95% CI 4.5-14.3, bootstrapped p < 0.001; HR 0.57 [95% CI 0.43-0.70]). Median PFS was 18.0 and 12.9 months in the respective groups, with an RMST difference of 6.7 months (95% CI 3.3-10.7, bootstrapped p = 0.001; HR 0.70 [95% CI 0.58-0.82]). Combination therapy also yielded a higher ORR per mRECIST (60.5% versus 44.3%; p < 0.001). Similar results for PFS and ORR were observed when assessed using RECIST 1.1. Grade ≥3 adverse events occurred in 64 (20.8%) and 43 (6.8%) patients, respectively. Interpretation:Combining TACE with ICIs and VEGF inhibitors or TKIs was associated with improved OS and PFS than TACE monotherapy, with an acceptable safety profile, supporting its potential as a first-line treatment strategy for intermediate-stage HCC. Funding:National Natural Science Foundation of China (82130060, 82502493), China Postdoctoral Science Foundation (2025M772071), Jiangsu Provincial Basic Research ProgramNatural Science Foundation-Frontier Leading Technology Basic Research Project (BK20232008), Jiangsu Provincial Medical Innovation Center (CXZX202219), Postdoctoral Fellowship Program of CPSF (GZC20251385), and Natural Science Foundation of Jiangsu Province (BK20251687).

To compare the efficacy and safety of transarterial chemoembolization (TACE) plus donafenib and immune checkpoint inhibitors (ICIs) (combination therapy) versus TACE monotherapy for intermediate hepatocellular carcinoma (HCC). This nationwide, multicenter, retrospective cohort study included intermediate HCC patients receiving either combination therapy or TACE monotherapy between January 2021 and May 2024. The primary outcome was progression-free survival (PFS). The secondary outcomes included overall survival (OS) rate, objective response rate (ORR), and safety. Propensity score matching (PSM) analysis was employed to minimize bias. The Cox proportional-hazards regression model was used to analyze factors affecting PFS and OS. Of 364 patients enrolled, 192 received combination therapy and 172 received TACE monotherapy with a baseline up-to-seven distribution (≤ 7 = 30

Predicting hepatic encephalopathy (HE) after transjugular intrahepatic portosystemic shunt (TIPS) is critical for guiding portal hypertension treatment strategies and enabling early intervention. This study aims to employ the Tabular Prior-data Fitted Network (TabPFN) algorithm to develop a machine learning (ML) model that predicts post-TIPS HE. This study retrospectively enrolled 218 patients who underwent TIPS across three hospitals. Preoperative contrast enhanced CT (CECT) scans were used to delineate the volumetric region of interest (VOI) for the liver, spleen, abdominal fat, and abdominal muscle. Radiomics and deep transfer learning (DTL) features were extracted from each VOI. Overt HE occurrence during follow-up was divided into two groups. 171 patients (two hospitals) were randomly split (7:3) into training and validation set, 47 patients (third hospital) formed an external test set. After feature selection, we trained and compared multiple ML models. Shapley additive explanation (SHAP) was performed for model interpretability. The overall incidence of overt HE in the study cohort was 20.6

BACKGROUND:Transjugular intrahepatic portosystemic shunt (TIPS) is an established procedure for managing portal hypertension in cirrhotic patients, but the impact of post-TIPS overt hepatic encephalopathy (OHE) on survival remains controversial. While its effect on short-term survival is well-documented, its long-term implications remain unclear. AIMS:This study aims to investigate the long-term impact of post-TIPS OHE on mortality in cirrhotic patients for variceal bleeding, focusing on the timing and predictive value of OHE beyond the first year post-TIPS. METHODS:A multicenter, retrospective cohort study was conducted involving 3262 cirrhotic patients who underwent TIPS for variceal bleeding at seven Chinese tertiary centers between January 2010 and June 2020. Clinical data, including demographics, procedure details, post-TIPS complications and survival outcomes, were collected. The primary endpoints were all-cause mortality and OHE, with follow-up until death, liver transplantation or 60 months. Propensity score matching minimised confounding effects, and multivariate Fine-Grey competing risk models identified independent mortality predictors. RESULTS:During a median follow-up of 1077 days, 33.2% developed post-TIPS OHE, associated with higher MELD and Child-Pugh scores. Among these, 19.3% died, with a median time from OHE onset to death of 947 days. Post-TIPS OHE was not linked to early survival (within 12 months) but emerged as an independent predictor of long-term mortality beyond 24 months, consistent across various clinical scenarios. CONCLUSION:Post-TIPS OHE does not affect short-term survival but significantly increases long-term mortality risk. These findings highlight the need for continuous monitoring and tailored interventions to improve long-term outcomes in post-TIPS patients.

BACKGROUND AND AIM:Patients with recurrent or refractory ascites can benefit from transjugular intrahepatic portosystemic shunt (TIPS). However, the value of TIPS for patients with large ascites remains unclear. METHODS:This retrospective multicenter study included patients who underwent TIPS or medicine plus large-volume paracentesis (medicine + LVP) for ascites between January 2014 and December 2022 at five centers. The primary endpoint was recurrence or worsening of ascites. The secondary endpoints were liver-related death, all-cause hemorrhage, overt hepatic encephalopathy (OHE), and shunt dysfunction. RESULTS:Overall, 724 patients were evaluated, including 373 patients with large ascites preceding recurrent or refractory ascites received TIPS (the LA-TIPS group), 282 patients with recurrent and refractory ascites received TIPS (the RA-TIPS group), and 69 patients with large ascites preceding recurrent or refractory ascites received medicine + LVP (the LA-M group). Patients in the LA-TIPS group had significantly lower incidences of recurrence or worsening of ascites (37.4% vs. 45.3%, p < 0.001), liver-related death (44.8% vs. 62.0%, p < 0.001), and OHE (47.3% vs. 60.3%, p < 0.001) than those in the RA-TIPS group. Meanwhile, patients in the LA-TIPS group had significantly lower incidences of recurrence or worsening of ascites (37.4% vs. 44.6%, p = 0.006) and hemorrhage (38.3% vs. 47.2%, p = 0.042), but a higher incidence of OHE (34.2% vs. 4.5%, p < 0.001) than those in the LA-M group. CONCLUSIONS:In terms of controlling ascites, the benefit of TIPS was greater in patients with large ascites preceding recurrent or refractory ascites, suggesting that TIPS might be considered in patients with large ascites before they progress to recurrent or refractory stages.

PURPOSE:To describe transjugular splenocaval shunt (TSCS) technique and evaluate its feasibility, safety, and effectiveness in patients with cavernous transformation of the portal vein (CTPV) and complete thrombosis of the superior mesenteric vein (SMV). MATERIALS AND METHODS:In this retrospective analysis, baseline data, procedural outcomes, adverse events, rebleeding episodes, stent patency, hepatic encephalopathy (HE), and survival were retrospectively analyzed in patients with CTPV and recurrent variceal hemorrhage who underwent TSCS. RESULTS:Eleven patients (median age, 52 years; range, 25-63 years) with CTPV, complete SMV thrombosis, and recurrent variceal hemorrhage were included. Technical success was achieved in all cases, with no procedural mortality. After TSCS, the median splenocaval pressure gradient decreased from 28 mm Hg (range, 23-34 mm Hg) to 7 mm Hg (range, 5-10 mm Hg). During a median follow-up of 22 months (range, 6-39 months), 1 patient experienced rebleeding due to stent stenosis, which resolved after revision. Another patient developed asymptomatic stenosis. One patient developed medically manageable HE, and 3 had transient hyperbilirubinemia. There were no deaths or permanent severe adverse events. CONCLUSIONS:TSCS appears to be a feasible and safe therapeutic option for patients with CTPV and complete SMV thrombosis who are refractory to conventional treatments.

We report a rare case of refractory gastrointestinal bleeding due to portal hypertension caused by a gastroduodenal artery-superior mesenteric vein fistula. A 54-year-old woman with a 6-year history of haematemesis and haematochezia was admitted after her most recent bleeding episode. She had endured over 10 episodes of gastrointestinal bleeding, undergone multiple endoscopic procedures and received one percutaneous transhepatic variceal embolisation. One week before admission, she experienced another bleeding episode, necessitating an emergency transjugular intrahepatic portosystemic shunt (TIPS). Six days post-TIPS, she returned with recurrent haematochezia. Preoperative CT revealed significant thickening and dilation of the superior mesenteric vein, indicating a possible fistula, which was confirmed through coeliac trunk angiography. We successfully occluded the fistula, leading to a reduced portal vein pressure gradient and the resolution of her symptoms. Portal hypertension resulting from an arteriovenous fistula is uncommon, and the closure of the fistula is essential for effective treatment.

BACKGROUND & AIMS: The effect of transjugular intrahepatic portosystemic shunt (TIPS) plus variceal embolization for treating gastric varices (GVs) remains controversial. This nationwide multicenter cohort study aimed to evaluate whether adding variceal embolization to a small diameter (8-mm) TIPS could reduce the rebleeding incidence in patients with different types of GVs. METHODS: This retrospective cohort study involved 629 patients who underwent 8-mm TIPS for gastric varices at 7 medical centers. The primary endpoint was all-cause rebleeding, and the secondary endpoints included overt hepatic encephalopathy (OHE) and all-cause mortality. RESULTS: A total of 629 patients were included. Among them, 429 (68.2%) had gastroesophageal varices type 1 (GOV1), 145 (23.1%) had gastroesophageal varices type 2 (GOV2), and 55 (8.7%) had isolated gastric varices type 1 (IGV1). In the entire cohort, adjunctive embolization reduced rebleeding (6.2% vs 13.6%; P = .005) and OHE (31.0% vs 39.4%; P = .02) compared with TIPS alone. However, no significant differences were found in mortality (12.0% vs 9.7%; P = .42). In patients with GOV2 and IGV1, TIPS plus variceal embolization reduced both rebleeding (GOV2: 7.8% vs 25.1%; P = .01; IGV1: 5.6% vs 30.8%; P = .03) and OHE (GOV2: 31.8% vs 51.5%; P = .008; IGV1: 11.6% vs 38.5%; P = .04). However, in patients with GOV1, adjunctive embolization did not reduce rebleeding (5.9% vs 8.7%; P = .37) or OHE (33.1% vs 35.3%; P = .60). CONCLUSIONS: Compared with TIPS alone, 8-mm TIPS plus variceal embolization reduced rebleeding and OHE in patients with GOV2 and IGV1. These findings suggest that patients with GOV2 and IGV1, rather than GOV1, could benefit from embolization with TIPS.

Abstract Background Performing transjugular intrahepatic portosystemic shunt with different diameter stents leads to different portal pressure gradients and clinical outcomes. However, which diameter is more beneficial is unclear. This study aimed to compare the efficacy of using 6-, 8-, and 10-mm stents in the prevention of variceal rebleeding among patients with advanced cirrhosis. Methods This retrospective study included patients who underwent transjugular intrahepatic portosystemic shunt across six medical centers between January 2010 and June 2020. The primary endpoint was death; secondary endpoints included rebleeding, overt hepatic encephalopathy, and shunt dysfunction. Propensity score matching was performed among stent diameter groups. Results Overall, 1,688 patients were included in the study; 6-, 8-, and 10-mm diameter stents were used in 95, 1504, and 89 patients, respectively. As for survival, only the 8-mm group had a lower mortality rate than the 10-mm group (56.3% vs. 59.4%; p = 0.029). The 6-mm group had a higher rebleeding rate than those in the 8- and 10-mm groups (62.5% vs. 38.4% and 22.0%, respectively; both p < 0.001). The 6- and 8-mm groups exhibited lower overt hepatic encephalopathy rates than that in the 10-mm group (36.1% vs. 50.0%, p = 0.029; 42.4% vs. 50.0%, log-rank p = 0.021). The 6- and 8-mm groups exhibited higher shunt dysfunction rates than that in the 10-mm group (45.6% vs. 17.6%, p = 0.005; 32.24% vs. 17.61%, p = 0.024). Conclusions Compared with 6- and 10-mm diameters, transjugular intrahepatic portosystemic shunt with 8-mm stents is optimal to balance rebleeding prevention and overt hepatic encephalopathy risk reduction for patients with advanced cirrhosis; overall survival was not impacted.

Background The role of transarterial chemoembolization (TACE) in the treatment of advanced hepatocellular carcinoma (HCC) is unconfirmed. This study aimed to assess the efficacy and safety of immune checkpoint inhibitors (ICIs) plus anti -vascular endothelial growth factor (anti-VEGF) antibody/tyrosine kinase inhibitors (TKIs) with or without TACE as first -line treatment for advanced HCC. Methods This nationwide, multicenter, retrospective cohort study included advanced HCC patients receiving either TACE with ICIs plus anti-VEGF antibody/TKIs (TACE-ICI-VEGF) or only ICIs plus anti-VEGF antibody/TKIs (ICIVEGF) from January 2018 to December 2022. The study design followed the target trial emulation framework with stabilized inverse probability of treatment weighting (sIPTW) to minimize biases. The primary outcome was overall survival (OS). Secondary outcomes included progression -free survival (PFS), objective response rate (ORR), and safety. The study is registered with ClinicalTrials.gov, NCT05332821. Findings Among 1244 patients included in the analysis, 802 (64.5%) patients received TACE-ICI-VEGF treatment, and 442 (35.5%) patients received ICI-VEGF treatment. The median follow-up time was 21.1 months and 20.6 months, respectively. Post -application of sIPTW, baseline characteristics were well-balanced between the two groups. TACEICI-VEGF group exhibited a significantly improved median OS (22.6 months [95% CI: 21.2 - 23.9] vs 15.9 months [14.9 - 17.8]; P < 0.0001; adjusted hazard ratio [aHR] 0.63 [95% CI: 0.53 - 0.75]). Median PFS was also longer in TACE-ICI-VEGF group (9.9 months [9.1 - 10.6] vs 7.4 months [6.7 - 8.5]; P < 0.0001; aHR 0.74 [0.65 - 0.85]) per Response Evaluation Criteria in Solid Tumours (RECIST) version 1.1. A higher ORR was observed in TACE-ICIVEGF group, by either RECIST v1.1 or modified RECIST (41.2% vs 22.9%, P < 0.0001; 47.3% vs 29.7%, P < 0.0001). Grade >= 3 adverse events occurred in 178 patients (22.2%) in TACE-ICI-VEGF group and 80 patients (18.1%) in ICI-VEGF group. Interpretation This multicenter study supports the use of TACE combined with ICIs and anti-VEGF antibody/TKIs as first -line treatment for advanced HCC, demonstrating an acceptable safety pro file. Copyright (c) 2024 Published by Elsevier Ltd. This is an open access article under the CC BY -NC -ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).

This study aimed to evaluate the feasibility, safety, and efficacy of the transjugular mesenteric-caval shunt (TMCS) as a treatment for the cavernous transformation of the portal vein (CTPV) and recurrent variceal bleeding. This retrospective case series was conducted with approval from the institutional review board. It involved seven patients diagnosed with CTPV and recurrent variceal bleeding who underwent the TMCS procedure. We analyzed the rate of procedural complications, incidents of rebleeding, stent stenosis, hepatic encephalopathy, and overall survival to assess treatment outcomes. The TMCS was successfully performed in all seven patients without any life-threatening complications. Postoperatively, one patient developed a lung infection and pleural effusion, which resolved with appropriate treatment. Additionally, two patients experienced an increase in total bilirubin levels, but there was no further deterioration in liver function. The median portal pressure gradient significantly decreased from a preoperative value of 27 mmHg (range 20–36 mmHg) to a postoperative value of 6 mmHg (range 4–11 mmHg). A notable improvement was observed in one cirrhotic patient, with liver function progressing from Child-Pugh class B (score 9) to class A (score 6). Over a median follow-up period of 14 months (range 7–18 months), none of the patients encountered rebleeding, stent stenosis, hepatic encephalopathy, or mortality. The TMCS appears to be a viable and effective alternative for managing CTPV with recurrent variceal bleeding. Its long-term outcome requires further evaluation. TMCS provides a promising treatment for patients with life-threatening CTPV complications when occluded portal vein cannot be recanalized and portal vein recanalization TIPS is not an option.

Objectives The efficacy of transjugular intrahepatic portosystemic shunt (TIPS) plus extrahepatic collateral embolisation (TIPS+E) in reducing rebleeding and hepatic encephalopathy (HE) post-TIPS was recently reported in a meta-analysis, but further validation is essential. This study aims to confirm the effectiveness of TIPS+E using real-world data.Methods The multicentre retrospective cohort included 2077 patients with cirrhosis who underwent TIPS±E (TIPS: 631, TIPS+E: 1446) between January 2010 and December 2022. Regression and propensity score matching (PSM) were used to adjust for baseline characteristic differences. After PSM, clinical outcomes, including rebleeding, HE, survival and further decompensation (FDC), were analysed. Baseline data from all patients contributed to the construction of prognostic models.Results After PSM, 1136 matched patients (TIPS+E: TIPS=568:568) were included. TIPS+E demonstrated a significant reduction in rebleeding (HR 0.77; 95% CI 0.59 to 0.99; p=0.04), HE (HR 0.82; 95% CI 0.68 to 0.99; p=0.04) and FDC (HR 0.85; 95% CI 0.73 to 0.99; p=0.04), comparing to TIPS. Significantly, TIPS+E also reduced rebleeding, HE and FDC in subgroup of using 8 mm diameter stents and embolising of gastric varices+spontaneous portosystemic shunts (GV+SPSS). However, there were no differences in overall or subgroup survival analysis. Additionally, the random forest models showed higher accuracy and AUROC comparing to other models. Controlling post-TIPS portal pressure gradient (pPPG) within 7 mm Hg<pPPG<8.5 mm Hg improved prognosis, especially in TIPS+E group.Conclusion Our real-world data validation confirms the high efficacy of TIPS+E in reducing rebleeding and HE, particularly when using 8 mm diameter stents, embolising GV+SPSS and maintaining an optimal pPPG.

Transjugular intrahepatic portosystemic shunt (TIPS) is recommended for treating recurrent and refractory ascites. However, determining the target portal pressure gradient (PPG) has been inconclusive. This multicentre cohort study explored the post-TIPS PPG potential range associated with improving survival. The study enrolled 276 patients, all of whom underwent covered TIPS for ascites treatment across four medical centers. The cumulative incidences of clinical outcomes were compared among groups categorized by potential PPG thresholds. During the whole follow-up period with a medium follow-up of 21.6 (7.5, 41.6) months, 122 (44.2