Three‐Dimensional Portal Vein Geometry Predicts Post‐ <scp>TIPS</scp> ‐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.