Ultra-Large Spontaneous Portosystemic Shunt is Correlated With a Higher Hepatic Venous Pressure Gradient and...

Spontaneous portosystemic shunts (SPSSs) frequently develop in individuals with cirrhosis. However, their clinical impact on the hepatic venous pressure gradient (HVPG) and liver function remains complex and a subject of ongoing debate. This retrospective study evaluated the relationship between SPSS diameter, particularly ultra-large SPSS, and HVPG, liver dysfunction, and their predictive value in patients with cirrhosis.

A retrospective study was conducted on 90 cirrhotic patients. The patients were categorized into three groups: no SPSS (none or φ < 3 mm), small SPSS (3 ≤ φ < 8 mm), and large SPSS (φ ≥ 8 mm). The large SPSS group was further stratified into large (8 ≤ φ < 14.5 mm) and ultra-large (φ ≥ 14.5 mm) subgroups based on a receiver operating characteristic (ROC)-derived cutoff for hepatic encephalopathy (HE). Clinical parameters, HVPG, and vascular diameters were analyzed.

The large SPSS group had higher total bilirubin and a higher incidence of HE than the no SPSS group. Within the large SPSS cohort, the ultra-large subgroup (≥ 14.5 mm) demonstrated significantly worse liver function (lower albumin, higher bilirubin, prolonged PT, increased INR, and poorer Child-Pugh/MELD scores), a higher proportion of Child-Pugh Class C, and elevated HVPG values (18.7 vs. 16.6 mmHg, p = 0.03) compared to the large subgroup. Critically, SPSS diameter showed a significant positive correlation with HVPG (R = 0.314, p = 0.013). The incidence of HE was also significantly higher in the ultra-large subgroup (55.52% vs. 11%, p = 0.001).

The portal pressure-lowering effect of SPSS does not correlate linearly with its diameter, exhibiting a threshold-dependent attenuation as shunt size exceeds 14.5 mm. This cutoff may serve as a predictor of increased risk for HE and liver dysfunction in cirrhosis, supporting its potential role in clinical risk stratification and decision-making for cirrhosis patients with SPSS.