Background & Aim: Transjugular intrahepatic portosystemic shunt (TIPS) is a well-established procedure for treating complications of portal hypertension (PH) in patients with cirrhosis. However, there is a gap in the knowledge in patients with PSVD, being a rare condition. This study aimed to evaluate the efficacy and outcomes of TIPS placement in patients with PSVD. Methods Retrospective, multicenter study in patients with histologically confirmed PSVD undergoing TIPS across 27 centers worldwide. Demographic, clinical, and procedural data were systematically documented. Time-to-event outcomes were analyzed using Cox proportional-hazards models. Results The cohort comprised 260 patients, 64% males, median age 52 years (40-63), with 66% having associated conditions, predominantly hematological disorders. Nodular regenerative hyperplasia was the most common histopathological finding (33%). Pre-TIPS portal vein thrombosis (PVT) was present in 47%, with complete occlusion in 14%. Median MELD score was 9 (8-11).All patients received covered stents, dilated to 10mm (39%) or 8mm (36%). Median portal pressure gradient decreased from 19 mmHg (15-23) to 8 mmHg (5-11); 76.54% reached a PPG <12 mmHg.After TIPS positioning, 93.2% of patients undergoing TIPS for bleeding from varices did not experienced rebleeding, while ascites was controlled in 86.3%; additionally, 36.2% discontinued diuretics.Stent dysfunction occurred in 22.7%, with thrombosis making up 54.2% of cases. Pre-TIPS PVT did not predict stent thrombosis (p=0.089), but prothrombotic genetic disorders increased the risk of post-TIPS PVT (HR: 4.30, 95%CI 1.85-10.32; p=0.003). Cardiac failure was observed in 5.8% of cases, and liver failure in 1.2%.Overt hepatic encephalopathy (oHE) occurred in 24%, with pre-TIPS ascites being the only independent risk factor (HR:2.52, 95%CI 1.30-4.9; p=0.006). During follow-up [31 months (34-66)], 4.2% of patients underwent liver transplants, and 14.6% died, with only 7 deaths directly caused by liver disease. Transplant-free survival was 30 months (25–58), with 93.0% at 1 year and 77.9% at 5 years. In multivariate analysis, ascites control after TIPS (HR: 0.28, 95%CI 0.098-0.82; p=0.02), bacterial infection after TIPS (HR: 3.28, 95%CI 1.12–9.58; p=0.03), and hematological disorders (HR: 0.19, 95%CI 0.04–0.87; p=0.033) predicted transplant or death. For non-liver-related deaths, hematological disorders (HR: 2.2, 95%CI 1.02–4.9; p=0.04) and CKD (HR 3.6, 95%CI 1.4–9.4; p=0.008) were independent factors. Conclusions In this large cohort, TIPS appears to be effective in managing complications of portal hypertension in PSVD patients, despite a high rate of stent dysfunction. Multidisciplinary evaluation and customized risk assessment remain essential due to the significant influence of the associated conditions on survival.

Background: Partial splenic embolization (PSE) is an established procedure widely used to treat hypersplenism and its associated symptoms. While its effects on portal hypertension are documented, they remain incompletely defined. AIM: To evaluate the safety and efficacy of PSE as secondary prophylaxis for variceal bleeding in patients ineligible for orthotopic liver transplantation (OLTx), transjugular intrahepatic portosystemic shunt (TIPS), and other endovascular treatments (EVT).Methods: All PSE procedures performed since January 2017 were retrospectively reviewed. Inclusion criteria comprised active or recent variceal bleeding with exclusion from OLTx, TIPS, and EVT. Exclusion criteria: traumatic splenic rupture and absence of informed consent. Clinical, endoscopic, and imaging data were collected. Procedure-related complications were recorded; long-term rebleeding-free survival was established as primary outcome.Results: Twenty-one patients were included (57% female; mean age 57 y). Ten patients (47.6%) had cirrhosis, of whom 2 had extensive portal vein thrombosis (PVT)/cavernoma. Among the remaining 11 patients, 8 (72%) had PVT/cavernoma; of these, 5 had JAK2-related myeloproliferative neoplasms and 1 had Factor V Leiden mutation. 18 patients (85%) had prior hepatic decompensation. At the time of PSE, 4 patients had active bleeding and 17 had hi-risk varices. Nine patients had ascites, including 3 with grade 2 ascites despite diuretic therapy. Mean hemoglobin was 10.3 g/dL, median platelet count was 73 × 10⁹/L, and mean MELD-Na was 12. Embolization techniques included acrylic glue (n=6), coils (n=6), microparticles (n=3), and combined approaches (n=6). Mean devascularized splenic volume was 65%. Adverse events occurred in 90% of patients: 85% were minor complications, predominantly post-embolization syndrome and pleural effusion. 3 patients (15.7%) had new-onset ascites. 2 patients developed partial splenic vein thrombosis that resolved with anticoagulation. No splenic abscesses occurred. Sepsis developed in 4 patients, including 1 related to multidrug-resistant organism (MDRO). During 5-year follow-up, variceal rebleeding occurred in 2 patients (9.5%). Eight patients (38%) died during follow-up, including 2 within 3 months; all had decompensated cirrhosis, sarcopenia, and multiple comorbidities, including HIV infection, at the time of PSE. All patients with acute variceal bleeding survived the procedure without rebleeding. Rebleeding-free survival rates were 95.8% at 30 days, 75.3% at 1 year, 70.3% at 2 years, and 42.5% at 5 years.Conclusion: PSE is effective as secondary prophylaxis for variceal rebleeding in patients excluded from OLTx, TIPS, and EVT. However, post-procedural complications are frequent, and mortality may occur in patients with uncontrolled ascites, sarcopenia, and multiple comorbidities. These findings suggest that PSE should be performed with caution, particularly in centers without specific expertise in this procedure.

Background & Aims: The prognostic impact of asymptomatic pulmonary hypertension (PulH) in compensated cirrhosis remains unclear, particularly following the 2022 ESC/ERS guidelines that lowered the diagnostic mPAP threshold to >20 mmHg and introduced the “unclassified PulH” phenotype. We evaluated whether the hemodynamic phenotype and severity of asymptomatic PulH influenced long-term survival. Methods. We retrospectively analyzed consecutive patients undergoing routine hepatic and right-heart catheterization between 2016 and 2023. PulH phenotypes were pre-capillary (mPAP >20 mmHg, PCWP ≤15 mmHg, PVR ≥2 WU), post-capillary (mPAP > 20mmHg, PCWP >15 mmHg), and unclassified (mPAP >20 mmHg, PCWP ≤15 mmHg, PVR <2 WU). Mild PulH was defined by mPAP 21–24 mmHg and conclamant by mPAP ≥25 mmHg. We excluded patients on beta-blockers, diuretics, and other drugs affecting cardio-pulmonary function. Five-year transplant-free survival (5y-TFS) and 5-year not liver-related mortality (5y-NLRM; censoring at first decompensation, HCC diagnosis, or first ACLF episode leading to death/transplantation) were assessed. Results. Among 1632 screened patients, 325 (20%) met no exclusion criteria; 198 (61%) presented with PulH. Unclassified PulH was most frequent (30%), followed by post-capillary (17%) and pre-capillary (14%). Liver function was preserved (MELD 10.4±3.8, Child-Pugh 5.7±1.2), and clinically significant portal hypertension was evident in 83%, without major differences between patients with or without PulH. During a mean follow-up of 4.9±2.7 years, 110 patients decompensated (34%), 89 developed HCC (27%), 115 died (35%), and 49 underwent transplantation (15%). Five-year TFS differed significantly across PulH phenotypes (67% no-PulH, 61% unclassified, 53% pre/post-capillary; p=0.01). Corresponding 5y-NLRM rates were 94%, 86% and 74% (p<0.001). Both TSF and NLRM pairwise comparison showed significant differences between no-PulH and either unclassified or pre/post-capillary PulH. TFS (67%, 60%, and 50% in no-PulH, mild, and conclamant PulH, respectively; p=0.006) and NLRM (94%, 82%, and 76%, respectively; p<0.001) both declined with increasing PulH severity. Pairwise contrasts showed significant differences between no-PulH and either mild or conclamant PulH in both frameworks. In multivariable analysis for NLRM, similar to TFS, PulH severity independently predicted mortality: mild PulH (HR 3.68, p=0.007) and conclamant PulH (HR 5.45, p<0.001), together with age (HR 1.07, p<0.001), CP score (HR 1.28, p<0.001), and hemoglobin (HR 0.82, p=0.011). Replacing severity with PulH phenotypes, unclassified PulH (HR 3.39, p=0.013) and pre/post-capillary PulH (HR 4.87, p<0.001) emerged as independent risk factors. Conclusions. In compensated cirrhosis, both PulH phenotype and severity have an independent impact on long-term survival.

BACKGROUND & AIMS:Portal hypertension is a major challenge in patients with cirrhosis requiring surgery. This study aimed to evaluate the efficacy of under-dilated neoadjuvant transjugular intrahepatic portosystemic shunt (U.N-TIPS) in enabling elective extrahepatic oncologic surgery in patients with cirrhosis and clinically significant portal hypertension (CSPH). METHODS:This retrospective multicenter analysis included 34 patients who underwent U.N-TIPS (diameter 5-7 mm) between June 2018 and April 2023. The primary outcome was the ability of U.N-TIPS to enable surgical interventions otherwise contraindicated. Secondary outcomes were perioperative complications, overt hepatic encephalopathy (OHE), heart failure, and survival rates at 6 months and 1 year post-TIPS. RESULTS:At baseline, 53% of patients had decompensated cirrhosis. The most common malignancies were colorectal (32%) and gastric (15%). Final diameters were 5/6/7 mm in 9/17/8 patients, respectively. Mean porto-caval pressure gradient (PCPG) significantly decreased from 21 ± 4.5 to 11 ± 3.2 mmHg (p < 0.001), with all patients achieving PCPG < 16 mmHg. Thirty-two patients (94%) underwent planned surgery, with a median TIPS-to-surgery interval of 42 days (IQR 45). Postoperative complications occurred in 38% of patients-mostly infections-and were independently associated with pre-surgery MELD score and haemoglobin. Post-TIPS OHE occurred in 22%, with no persistent cases; symptomatic heart failure developed in 6%. Six-month and one-year survival rates were 85% and 76%, respectively, without significant difference between pre-TIPS compensated and decompensated patients (p = 0.21). CONCLUSIONS:U.N-TIPS represents an applicable strategy for enabling curative oncologic surgery in selected patients with cirrhosis and CSPH. Under-dilation reduces shunt-related complications while preserving hemodynamic efficacy, expanding TIPS applicability. IMPACT AND IMPLICATIONS:U.N-TIPS addresses the critical barrier of portal hypertension in oncologic patients with cirrhosis, offering access to surgical treatments considered unfeasible while maintaining an adequate safety profile. These findings are particularly significant for hepatologists, oncologists, interventional radiologists, and surgeons managing the increasingly common clinical scenario of cirrhosis with concurrent extrahepatic malignancies. In clinical practice, our results support the implementation of multidisciplinary tumour boards that incorporate portal pressure assessment and TIPS indication in pre-surgical planning. However, large, controlled studies are needed to compare outcomes between compensated patients with CSPH who undergo U.N-TIPS versus those who do not receive this intervention.

BACKGROUND & AIMS:Under-dilated trans-jugular intra-hepatic porto-systemic shunt (U-TIPS, ≤ 7 mm) effectively controls portal hypertension (PH) complications that placed the indication to TIPS while reducing the incidence of hepatic encephalopathy. However, TIPS efficacy in preventing additional PH-complications is reported only for standard endoprosthesis dilation (≥ 8 mm, S-TIPS). This study evaluated whether U-TIPS provides protection comparable to S-TIPS against PH-complications beyond the initial indication, independent of achieving guideline-defined hemodynamic targets. METHODS:Patients treated for refractory ascites (RA) or secondary prophylaxis of PH-related bleeding (PHRB) were included. Adequate hemodynamic response (AHR) was defined as post-TIPS PCPG < 12 mm Hg in RA, and < 12 mm Hg or reduction ≥ 50% in PHRB. Porto-caval pressure gradient (PCPG) values outside these criteria were deemed an inadequate response (IHR). Post-TIPS spontaneous bacterial peritonitis, acute renal injury hepatorenal syndrome-related, hepatic hydrothorax, need for paracentesis, and bleeding, were assessed individually and as a composite endpoint over one year. RESULTS:Of 358 patients, 257 (72%) received U-TIPS and 101 (28%) S-TIPS. The incidence of at least one post-TIPS event was higher in S-TIPS vs. U-TIPS (14% vs. 6%, p = 0.022), with no significant difference between AHR and IHR groups (9% vs. 7%, p = 0.543). On multivariable analysis, S-TIPS (OR 3.13, 95% CI 1.38, 7.21, p = 0.006), Child-Pugh class B (OR 11.6, 95% CI 2.14, 217, p = 0.021) and C (OR 14.4, 95% CI 1.17, 343, p = 0.042), higher MELD score (OR 1.20, 95% CI 1.09, 1.32, p < 0.001) were independently associated with post-TIPS events. CONCLUSIONS:U-TIPS provides non-inferior protection against other PH-complications irrespective of achieving hemodynamic efficacy targets.

Background: Refractory hepatic hydrothorax (RHH) develops in up to 15% of patients with cirrhosis and significantly impairs quality of life and clinical outcome of these patients. Transjugular intrahepatic portosystemic shunt (TIPS) has been suggested as a potential treatment. Still, its impact on both clinical efficacy and transplant-free survival (TFS) is uncertain, with data based on small and relatively old studies. Methods. We conducted a multicenter retrospective study including all consecutive patients with cirrhosis who underwent TIPS for RHH in a 16-year period (2008-2023) across 18 European centers. Efficacy and survival were assessed at the last available evaluation during a 1-year follow-up: after 12 months from TIPS, at the date of liver transplant (LT) or death, at the date of the last available visit for patients lost to follow-up. Clinical response was classified as: 1- complete (CR) in case of disappearance of symptoms and no further need for thoracenteses; 2- partial (PR) as decrease of at least 50% of symptoms and/or of need for thoracenteses; 3- null (NR) as no relief in symptoms and/or same or increased need for thoracenteses. Results. A total of 155 patients were included in the analysis. Alcohol was the prevalent etiology (47%), with moderately impaired liver and renal function (Child-Pugh class B 78%, median MELD-Na 15), prevalent right unilateral HH (85%). TIPS improved HH in the majority of patients (88% overall), with 61% of CR. Inter-center variability in clinical CR was modest and not significant with an Intraclass Correlation Coefficient of 0.06 (95% CI -0.19–0.18, p = 0.08). At 12 months after TIPS, 76 patients (49%) were alive, 36 (23%) were deceased, 23 (15%) underwent LT and 20 (13%) were lost to follow-up. Mean TFS was 9.9 ± 0.3 months. TFS was 11.0 ± 0.3 months for CR patients vs 8.4 ± 0.8 months vs 6.9 ± 1.2 months, for PR and NR patients respectively (Log-rank test: p < 0.001; Cox regression: HR = 0.22, 95% CI 0.11–0.43; p < 0.001). Significantly improved survival for CR patients was also confirmed when considering CR to TIPS as a time-varying covariate (HR = 0.25; 95% CI 0.13–0.48; p < 0.001). At multivariable analysis, considering LT as competitive event, clinical CR was the only variable independently associated with improved survival (sHR = 0.28, 95% CI 0.15–0.55, p < 0.001); conversely, bilateral HH and MELD-Na score were independently associated with poorer survival (sHR = 2.55, 95% CI 1.34–4.85, p = 0.004 and sHR = 1.10, 95% CI 1.05–1.15, p < 0.001, respectively). Conclusions. Our study supports the use of TIPS in patients with cirrhosis and RHH, showing that a clinical CR is achieved in a relevant proportion of patients and is associated with improved medium-term TFS.

BACKGROUND AND AIMS:Screening endoscopy can be spared in patients with compensated cirrhosis when spleen stiffness measurement (SSM) by vibration-controlled transient elastography (VCTE) is ≤40 kPa, as they have a low probability of high-risk varices (HRV). Conversely, endoscopy is required in all patients with chronic portal vein thrombosis (PVT) without cirrhosis. The objective was to evaluate the performance of SSM-VCTE to exclude HRV in patients with chronic PVT. METHODS:We retrospectively included patients with chronic PVT without cirrhosis, who underwent an upper endoscopy within 2 years before or after SSM-VCTE in 16 VALDIG centers, divided into a derivation and a validation cohort. RESULTS:159 patients were included in the derivation cohort; 43% had HRV. 187 patients were included in the validation cohort; 32% had HRV. By univariable analysis, myeloproliferative neoplasm, ascites, hemoglobin, bilirubin, albumin, splenomegaly, portosystemic collaterals, liver stiffness - spleen diameter to platelet ratio score, liver stiffness measurement and SSM-VCTE were associated with HRV in both cohorts. By multivariable binary logistic regression analysis, only SSM-VCTE (p <0.005) remained associated with HRV in both cohorts. In the derivation cohort, SSM-VCTE ≤ 40 kPa had a sensitivity of 97% to rule out HRV, and could spare 41% of endoscopies, with 3% of HRV missed, and a 97% negative predictive value (NPV). In the validation cohort, SSM-VCTE ≤ 40 kPa could spare 43% of endoscopies, with 5% of HRV missed, and a 96% NPV. CONCLUSIONS:This study gathering a total of 346 patients with chronic PVT without cirrhosis showed that SSM-VCTE ≤ 40 kPa can be used to identify patients with a probability of HRV ≤5%, in whom endoscopy can be spared. IMPACT AND IMPLICATIONS:Patients with chronic portal vein thrombosis who do not have cirrhosis usually have low liver stiffness measurement values; the liver stiffness cut-offs used to rule out high-risk varices in patients with cirrhosis cannot therefore be used in this population. We show here that spleen stiffness measurement by vibration-controlled transient elastography ≤40 kPa is able to identify patients with chronic portal vein thrombosis with a very low probability of high-risk varices, in whom screening endoscopy can be spared. Annual surveillance of spleen stiffness measurement could reduce the need for repeated screening endoscopies throughout a person's lifetime. This approach could enhance quality of life while also reducing risks associated with endoscopic procedures, particularly those related to anesthesia.

Background & Aims: Portal hypertension (PH) is a major determinant of poor prognosis in cirrhosis. An under-dilated transjugular intrahepatic portosystemic shunt (U-TIPS) effectively controls PH-related complications that constitute the indication for the procedure, while reducing the incidence of post-TIPS overt hepatic encephalopathy. However, the benefits of TIPS in preventing additional PH-related complications beyond the initial indication have been reported only for standard-diameter stents (≥8 mm, S-TIPS). This study evaluated whether U-TIPS provides protection comparable to S-TIPS against further PH-related complications beyond the initial indication, independently of achieving guideline-defined hemodynamic targets for TIPS success.Methods: Patients treated for refractory ascites (RA) or for secondary prophylaxis of PH-related bleeding (PHRB) were included. Adequate hemodynamic response (AHR) was defined as a post-TIPS porto-caval pressure gradient (PCPG) <12 mmHg in RA, and <12 mmHg or a reduction ≥50% in PHRB. PCPG values outside these thresholds were considered an inadequate hemodynamic response (IHR). S-TIPS was defined as endoprosthesis dilation >7 mm. Post-TIPS PH-related complications beyond the initial indication—spontaneous bacterial peritonitis, acute kidney injury due to hepatorenal syndrome, hepatic hydrothorax, need for paracentesis, and variceal bleeding—were assessed individually and as a composite endpoint over one year. Results: A total of 358 patients were included, of whom 257 (72%) received U-TIPS and 101 (28%) S-TIPS. The incidence of at least one post-TIPS complication was significantly higher in S-TIPS compared with U-TIPS (14% vs. 6%, p=0.022), while no significant difference was observed between AHR and IHR groups (8.7% vs. 6.7%, p=0.543). On multivariable analysis, S-TIPS (OR 3.13, 95% CI 1.38–7.21, p=0.006), Child-Pugh class B (OR 11.6, 95% CI 2.1–217, p=0.021) and C (OR 14.4, 95% CI 1.2–343, p=0.042), and higher MELD score (OR 1.20, 95% CI 1.09–1.32, p<0.001) were independently associated with post-TIPS complications. Conclusions: U-TIPS provides non-inferior protection against additional PH-related complications compared with S-TIPS, irrespective of the achievement of guideline-defined hemodynamic efficacy targets.

Background & Aims: Overt hepatic encephalopathy (OHE) continues to be the primary complication following transjugular intrahepatic portosystemic shunt (TIPS) placement. It significantly impairs patients' health-related quality of life, particularly in its recurrent and persistent forms, and may outweigh the benefits of the procedure. This study aimed to develop and internally validate a prognostic score incorporating quantified electroencephalography (qEEG) to predict the risk of post-TIPS recurrent OHE at 3 and 6 months. Methods: We prospectively enrolled 161 consecutive patients with cirrhosis undergoing elective TIPS for refractory or recurrent ascites or secondary prophylaxis of variceal bleeding. All patients underwent qEEG assessment using validated spectral analysis criteria prior to TIPS placement. A multivariable Cox regression model was constructed to estimate the risk of recurrent OHE. Model performance was evaluated using time-dependent ROC curves, calibration plots, decision curve analysis, and internal validation via bootstrap resampling (B = 1,500). Results: Independent predictors of recurrent OHE included age, serum albumin, prior OHE history, and qEEG alterations, which were incorporated into the novel qEEG-TIPS score. The time-dependent AUCs were 0.76 (95% CI 0.70-0.82) and 0.80 (95% CI 0.76-0.85) at 3 and 6 months, respectively. The score identified high-risk patients with a significantly greater incidence of recurrent OHE at 6 months (48% vs. 8% in low-risk patients, p <0.001). Internal validation yielded an optimism-corrected C-index of 0.74 (95% CI 0.69-0.84), indicating mild overfitting but good predictive stability. Decision curve analysis supported the clinical utility of the model. Conclusions: The qEEG-TIPS score demonstrated good discrimination and calibration in predicting short-term risk of recurrent OHE after TIPS. This tool may assist in risk stratification and guide personalized management both before and after TIPS. Impact and implications: Recurrent overt hepatic encephalopathy (OHE) is the primary complication of transjugular intrahepatic portosystemic shunt (TIPS) in patients with cirrhosis, markedly reducing quality of life, increasing healthcare burden, and complicating clinical decision-making. This study introduces and internally validates the qEEG-TIPS score, a novel, non-invasive tool integrating quantified electroencephalography with clinical variables to predict the short-term risk of recurrent OHE after elective TIPS. These findings hold particular relevance for patients, hepatologists, and transplant teams as they enable more personalized risk assessment prior to TIPS and may guide decisions on prophylaxis, patient selection, and post-procedural monitoring. If externally validated, the qEEG-TIPS score could enhance clinical pathways by identifying high-risk patients for targeted interventions, supporting more cost-effective and patient-centered TIPS management strategies.

Introduction: Nutritional status is a key element when selecting candidates for Transjugular Intrahepatic Portosystemic Shunt (TIPS). Sarcopenia is a known risk factor for adverse outcomes after TIPS; on the other hand, TIPS may improve muscle and adipose tissue composition, suggesting a potential benefit of this procedure in patients with liver cirrhosis. At present, available evidence is however limited and largely retrospective. Aim: To evaluate the impact of TIPS on body composition—including muscle mass, myosteatosis, and adiposity—and to assess its prognostic value, particularly for the incidence of post-TIPS hepatic encephalopathy (HE).Materials and Methods: Patients with cirrhosis undergoing TIPS were prospectively enrolled across six Italian centers (2021–2025). Clinical, hemodynamic, and nutritional data were collected. Skeletal muscle index (SMI), muscle attenuation, visceral and subcutaneous adipose tissue (VAT and SAT) and radiointensity of SAT (RSAT) were assessed by CT at L3–L4 at baseline and after 6 months. Clinical outcomes were recorded during follow-up. Results: Among 102 enrolled patients (75% male; median age 61 yrs), baseline sarcopenia and myosteatosis were present in 54% and 81%, respectively. Mean VAT and SAT areas were 106 mm² and 134 mm², respectively; mean RSAT was -92 HU (IQR -98 to -78), with 23 patients showing high RSAT. The median VAT/SAT ratio was 0.92 (0.55–1.28). In the 84 patients who reached 6 months follow-up, SMI increased significantly (51.9 vs 48.0, p<0.001); thirty-four patients (40.7%) had ≥10% increase in SMI, with 15 (17.8%) reclassified as non-sarcopenic. VAT decreased (109.6 vs 146.8 mm², p<0.001) and SAT increased (193.5 vs 172.6 mm², p<0.001), while RSAT remained unchanged (-85.7 vs -88.1 HU). HE occurred in 45% of patients. Prevalence of sarcopenia at basal was not different in patients who developed or did not develop HE after TIPS (54% for both groups). Lower muscle attenuation and higher RSAT were associated with increased HE prevalence (p 0.029 and 0.028 respectively) and higher RSAT was also linked to higher ascites recurrence (p 0.023) and TIPS failure (p 0.029). These associations were not retained after adjustment for age, MELD, and prior HE. Conclusions: This is the first prospective multicenter study on body composition after TIPS, showing improved muscle mass and more favorable adipose tissue distribution, leading to a partial reversal of sarcopenia. Baseline muscle attenuation and SAT radiodensity—markers of systemic inflammation—appear to be more informative prognostic indicators of post-TIPS complications than muscle mass alone.