Long-term outcomes of TIPS assessed by MRI features in patients with portal hypertension and hepatocellular carcinoma: A retrospective study

In hepatocellular carcinoma (HCC) complicated by portal hypertension (PHT), transjugular intrahepatic portosystemic shunt (TIPS) relieves portal pressure but its long-term net benefit remains debated. Multiparametric magnetic resonance imaging (MRI) may refine candidate selection by capturing tumor biology and hepatic hemodynamics. We conducted a single-center retrospective cohort (January 2020-December 2022) including 150 HCC patients with PHT who underwent baseline MRI (TIPS, n = 80; control, n = 70). Demographics, liver function, tumor burden, and MRI metrics - tumor apparent diffusion coefficient (ADC), liver stiffness by magnetic resonance elastography, and spleen volume - were collected. The primary endpoint was 36-month overall survival (OS); secondary endpoints were progression-free survival (PFS), ≥Grade II overt hepatic encephalopathy (OHE), variceal rebleeding, and TIPS stenosis. Survival was compared by Kaplan-Meier analysis; independent predictors were identified using Cox models. A nomogram incorporating TIPS, ADC, liver stiffness, Child-Pugh class, and alpha-fetoprotein was built and validated. At 36 months, the TIPS group showed higher OS than controls (69.0% vs 50.0%; HR 0.56, 95% CI: 0.34-0.92; P = .021) and better PFS (65.0% vs 42.9%; P = .006). Rates of death, disease progression, OHE, and rebleeding were all reduced with TIPS (all P < .05). Higher tumor ADC (≥1.10 × 10-3 mm2/s; HR 0.48, 95% CI: 0.29-0.80) and lower liver stiffness (<5 kPa; HR 0.63, 95% CI: 0.40-0.98) independently predicted improved OS, whereas Child-Pugh C was adverse (HR 1.72, 95% CI: 1.05-2.80). The MRI-clinical nomogram achieved area under the receiver operating characteristic curves (AUCs) of 0.830, 0.820, and 0.798 for predicting 1-, 2-, and 3-year OS, with favorable calibration and decision-curve net benefit. TIPS confers a significant long-term survival advantage in HCC with PHT while reducing major complications. Quantitative MRI metrics (tumor ADC and liver stiffness) refine preprocedural risk stratification, and the combined MRI-clinical nomogram provides practical decision support.