This study aimed to assess the prognostic significance of pretreatment CT-based body composition markers in patients with Hepatocellular carcinoma (HCC) treated with radioembolization. Automated analysis of baseline CT scans was performed to retrospectively evaluate body composition (BCA) parameters in 198 patients from a prospective registry database, including skeletal muscle (SM) and bone (B) volumes. BCA parameters and ratios were dichotomized using a maximally selected log-rank approach. Kaplan-Meier and uni- (UVA) and multivariate (MVA) Cox-proportional-hazard ratio (HR) survival analyses were performed. The median survival time was 18.5 months. In UVA, lower BCLC stage, ≦ 70 years of age, normal serum albumin, non-elevated C-reactive protein, normal aspartate aminotransferase (ASAT), normal alkaline phosphatase, normal gamma-glutamyl transaminase (GGT), absence of portal vein thrombosis and various BCA parameters were statistically significant with the skeletal muscle to bone ratio (SM/B) demonstrating the strongest survival discrimination with a median survival of 23.6 months for high and 12.0 months for low SM/B (HR: 0.65, 95 %CI: 0.46-0.9; p = 0.0001). In MVA, SM/B, BCLC stage, ASAT, and GGT remained independently significant. Patients with higher SM/B ratios demonstrated a significantly higher disease control rate during the initial imaging follow-up after three months (74.4 % vs. 54.0 %, p = 0.017). These findings suggest that fully automated, CT-based measurement of BCA parameters - particularly the SM/B ratio - can serve as an independent prognostic factor for survival and disease control in patients with Hepatocellular carcinoma (HCC) undergoing radioembolization. This could potentially facilitate the identification of patients who would benefit most from this treatment.

Porto-sinusoidal vascular disorder (PSVD) was defined by the Vascular Liver Disease Interest Group in 2019 and encompasses conditions that cause portal hypertension in patients without cirrhosis. Nodular regenerative hyperplasia (NRH) is a pathological finding associated with PSVD. We encountered a patient with refractory ascites who underwent transjugular liver biopsy and was diagnosed with PSVD. The patient subsequently underwent transjugular intrahepatic portosystemic shunt (TIPS) placement for refractory ascites and recurrent variceal bleeding caused by portal hypertension, which resolved the ascites and improved the varices. Post-procedural complications, including hepatic ischemia, portal vein thrombosis, and hepatic encephalopathy, were observed but improved with conservative treatment. TIPS can be a feasible treatment option for patients with portal hypertension associated with non-cirrhotic conditions such as PSVD.

ABSTRACTAimsTo explore a safe and effective treatment modality for unresectable huge (≥ 10 cm) hepatocellular carcinoma with portal vein thrombosis. And to provide more data on the synergistic antitumor effects of radiotherapy combined with immune checkpoint inhibitors and antiangiogenic therapy.Materials and MethodsThis study compared the clinical outcomes in 63 patients with unresectable huge hepatocellular carcinoma and portal vein thrombosis who were treated with either γ‐ray body radiotherapy or linear accelerator radiotherapy (the RTγ and RTa groups, respectively), both combined with immune checkpoint inhibitors and antiangiogenic therapy.ResultsThe median progress‐free survival (PFS) and median overall survival (OS) in the RTγ group were 12.1 and 14.3 months, respectively. And those in the RTa group were 6.6 and 8.1 months, respectively. The 1‐, 2‐, and 3‐year PFS were 43.2%, 24.3%, 10.8% in the RTγ group and 11.5%, 3.8%, 0% in the RTa group, respectively. The OS at the same intervals were 56.7%, 40.5%, and 18.9% in the RTγ group, and those were 23.1%, 7.7%, and 0% in the RTa group, respectively. The percentage of normal liver volume (NLV) in whole liver volume (WLV) > 60% and negative viral infection are significant independent factors for superior PFS and OS. Severe radiation‐induced liver disease was observed in 23.1% (n = 6) of patients in the RTa group, compared to none in the RTγ group.ConclusionsRTγ combined with immune checkpoint inhibitors and antiangiogenic therapy is an effective and safe treatment modality for unresectable huge hepatocellular carcinoma with portal vein thrombosis. An NLV/WLV ratio > 60% and negative viral infection independently predicted better PFS and OS.

The impact of early allograft dysfunction severity on graft and recipient outcomes in pediatric liver transplantation.

To investigate whether the presence of baseline portal vein thrombosis (PVT) and its anatomical subtypes influence long-term outcomes in cirrhotic patients with esophagogastric variceal bleeding (EGVB) undergoing technically successfultransjugular intrahepatic portosystemic shunt (TIPS). This retrospective cohort study included 140 cirrhotic EGVB patients who underwent successful TIPS between 2017 and 2024. Patients were stratified into groups with (n = 52) and without baseline PVT (n = 88) based on cross-sectional imaging. PVT was subclassified into simple (main trunk only) and mixed (extending to branches/mesenteric veins) types. The primary composite endpoint included all-cause mortality, variceal rebleeding, or shunt dysfunction. Kaplan-Meier analysis and multivariable Cox regression were performed. Median follow-up was 1286days. Composite endpoint events occurred in 59 patients (42.1%), with no significant difference betweenpatients with and without PVT (40.4% vs. 43.2%, P = 0.742). Cumulative event-free survival was comparable (log-rank P = 0.650). Within the PVT cohort, no difference was observed between simple and mixed subtypes (HR = 0.80, P = 0.736). Multivariable analysis confirmed thatbaselinePVT was not an independent predictor of adverse outcomes (HR = 0.92, P = 0.799). However, higherbaselineportal pressure gradient (PPG) (HR = 1.09 per mmHg, P = 0.002) and priorhistory ofovert hepatic encephalopathy (OHE) (HR = 3.33, P = 0.040) wereidentified as independent predictors. Baseline PVT, regardless of morphological subtype, does not appear to adversely affect long-term outcomesin the specific cohort of patients in whom TIPS is technically feasible and successful.Higher baseline PPG and history of OHE are primary determinants of long-term prognosis.

BACKGROUND Complete portal vein thrombosis (PVT) is a severe form of PVT that carries a high risk of portal hypertension-related complications and poses major therapeutic challenges. Although contrast-enhanced computed tomography (CT) is widely used for diagnosis and treatment planning, current classifications in both international and domestic practice are largely time-based (acute vs chronic). However, clinical onset frequently fails to align with true histopathological maturity, particularly in cases of complete occlusion. Consequently, establishing an objective, imaging-based classification system is essential to accurately characterize thrombus biology and guide tailored intervention strategies. AIM To analyze the radiological signs on contrast-enhanced CT images of the livers of patients with complete PVT, propose a new classification scheme, and establish the clinical significance of the scheme. METHODS We retrospectively analyzed 171 patients who were diagnosed with complete PVT treated at one of three Beijing centers from January 2018 to December 2023. Among patients without contraindications to anticoagulation who underwent interventional or surgical treatment combined with or followed by anticoagulation therapy, thrombus samples were obtained from 102 cases for pathological examination. Treatment outcomes were compared among groups based on the newly proposed imaging feature-based thrombus classifications. RESULTS Acute PVT (26.9%) was characterized by very low-density thrombus shadows in the blood vessel with uniform density, absent or minimal collateral blood vessel formation and no vascular wall thickening. Chronic PVT accounted for 34.5% of the patients, characterized by somewhat low-density thrombus shadows in the blood vessel, potentially with uneven density, increased collateral blood vessel formation, and thickening of the blood vessel wall. Cavernous transformation, which was observed in 12.9% of patients, involved the complete replacement of normal vascular anatomy with collateral vessels, whereas mixed PVT (25.7%) displayed heterogeneous features. Pathological examination revealed that different compositions correlated with distinct thrombus types. The posttreatment portal pressure gradient significantly decreased across all groups (P < 0.001), indicating favorable therapeutic efficacy. CONCLUSION Complete PVT has distinct properties and imaging manifestations. The proposed new thrombosis classification includes four types with distinct properties. Thrombosis with acute or chronic properties can be treated locally or with thrombolysis with good results.

Cirrhosis is associated with a narrow balance between procoagulant and anticoagulant factors that may lead to potentially serious complications. Interpretation of laboratory tests, prevention of bleeding during invasive procedures, and use of anticoagulant drugs for the prevention and treatment of thromboembolism are often challenging. After reviewing the most contemporary literature, we hereby provide guidance to navigate the evidence and support clinical decisions. Based on current knowledge, prothrombin time and activated partial thromboplastin time do not accurately describe hemostasis in patients with cirrhosis and should not be used to predict bleeding. Rather, a careful assessment of patient and procedure-related variables better helps to identify patients at increased bleeding risk. Because procedure-related bleedings are uncommon in patients with cirrhosis, the use of prophylactic strategies is seldom necessary in daily practice. In case of perioperative bleeding, viscoelastometry may be useful to drive decisions on the use of transfusion products. Portal vein thrombosis is a common complication in patients with cirrhosis and requires a timely start of anticoagulant treatment, especially when vessel obstruction exceeds 50% of the lumen diameter. Treatment should be continued for at least 6 months. The direct oral anticoagulants are increasingly used in this setting, representing a valid alternative to the heparins and vitamin K antagonists. Atrial fibrillation in cirrhosis is associated with a high risk of ischemic stroke and treatment-related major bleeding. The benefit of anticoagulants is supported by the results of observational studies, and the direct oral anticoagulants are suggested as the first line of treatment also for this population. Clinical trial number: not applicable.

Incident venous thromboembolism in biopsy-proven metabolic dysfunction-associated steatotic liver disease: a nationwide cohort study.

Safety and Effectiveness of Radiation Lobectomy for Primary Liver Cancers Using Resin Microspheres.

Background/Objectives: Portal vein thrombosis (PVT) is a clinically significant condition in which early risk stratification remains challenging, particularly in emergency settings where rapid decision-making is required. This study aimed to evaluate the prognostic value of the Systemic Immune-Inflammation Index (SII), Systemic Inflammation Response Index (SIRI), and the Model for End-Stage Liver Disease (MELD) score in predicting the need for intensive care in patients with PVT. Methods: A retrospective analysis was conducted on adult patients (>18 years) diagnosed with PVT in the emergency department between January 2018 and December 2024. A total of 29 patients meeting the inclusion and exclusion criteria were included. Demographic characteristics, laboratory parameters, Intensive Care Unit (ICU) admission status, and 90-day mortality were analyzed. The sensitivity and specificity of MELD, SII, and SIRI for predicting ICU admission were calculated. Non-normally distributed variables were expressed as median (interquartile range, IQR) and compared using the Mann–Whitney U test. Results: The mean age of patients was 60.5 ± 16.2 years, and 18/29 (62.1%) were male. ICU admission was required in 9/29 (31.0%) of cases. MELD score (median 18.7 [11.0–21.9] vs. 7.9 [6.7–13.5], p = 0.003), bilirubin (median 2.4 [1.0–4.2] vs. 0.7 [0.4–1.1], p = 0.016), and SIRI (median 6.4 [2.3–21.3] vs. 1.4 [0.6–9.3], p = 0.038) were significantly higher in ICU-admitted patients. MELD score showed 66.7% sensitivity and 95% specificity, while SIRI had 88.9% sensitivity and 55% specificity for ICU prediction. Conclusions: MELD score, bilirubin, and SIRI are significantly associated with ICU admission in PVT patients. Their integration into emergency department protocols may assist in early risk stratification and resource allocation.

Liver transplantation (LT) is the standard of care for children with end-stage liver disease, but waitlist mortality remains high, especially among infants. ABO-incompatible (ABO-I) LT offers a strategy to expand the donor pool, though concerns over antibody-mediated rejection have limited widespread use. We analyzed outcomes of recipients of ABO-I LT using the Society of Pediatric Liver Transplantation (SPLIT) registry from 2011 to 2022, a prospective, multicenter database capturing over 75% of pediatric LTs in the United States and Canada. Clinical characteristics, posttransplant complications, and graft and patient survival were compared between matched ABO-I and ABO-compatible (ABO-C) recipients. Recipients of ABO-I transplant were matched 1:5 with recipients of ABO-C using year of transplant, age, and clinical status at the time of transplant. A center-level survey assessed institutional practices regarding ABO-I LT. Among 3372 pediatric recipients of LT, 155 received ABO-I grafts and were matched to 775 recipients of ABO-C grafts. Recipients of ABO-I had higher rates of ventilator support, parenteral nutrition, and ICU care at the time of transplant compared with recipients of ABO-C. There was no statistically significant difference in 3-year graft (87.8% vs. 92.6%, p =0.06) or patient survival (93.9% vs. 96.6%, p =0.11) between ABO-I and ABO-C groups. In children ≤2 years of age, there was a higher incidence of early portal venous thrombosis in the ABO-I group (8.5% vs. 3.7%, p =0.025). Survey responses revealed substantial variability in center ABO-I eligibility criteria, desensitization protocols, and immunosuppressive strategies. Outcomes for pediatric recipients of ABO-I and ABO-C LT within the SPLIT registry are comparable, supporting broader implementation of ABO-I LT to reduce pediatric waitlist mortality. Variability in institutional practices underscores the need for prospective studies to inform standardized protocols and optimize outcomes.

The present study analyzes the complications requiring unplanned abdominal reoperation (Early Unplanned Reoperation [EUReop]) following liver transplantation (LT), its impact on short- and long-term outcomes, and identifies its predictors. A single-center retrospective analysis including all consecutive adult LT performed from 2007 to 2018. The impact of EUReop on 90-d mortality was assessed using multivariate analysis, and the failure to rescue (FTR) after EUReop was evaluated. Long-term outcomes were assessed using Kaplan-Meier curves. Predictors of EUReop were identified through multivariate logistic regression. Among 1213 LT, 203 patients (17%) required EUReop within a median of 6 d. The leading causes were bleeding (n = 114, 56%), arterial (n = 24, 12%), wound disruption or collection (n = 14, 7%), and biliary complications (n = 12, 6%). Independent predictors of EUReop included intensive care unit admission at LT (adjusted odds ratio: 3.0 [95% confidence interval, 1.7-5.7]), portal vein thrombosis (2.6 [1.5-4.2]), partial liver graft (1.8 [1.0-3.2]), hospitalization at LT (1.7 [1.1-2.7]), inferior vena cava replacement (1.7 [1.1-2.7]), elective re-LT (1.7 [1.0-2.8]), transfusion ≥4 units of red blood cells (1.7 [1.1-2.6]). FTR rate following EUReop was 12%, associated with Balance of Risk score and higher transfusion requirements during LT. The FTR rate significantly decreased over the study period. EUReop was an independent predictor of 90-d mortality (adjusted odds ratios 2.6 [1.4-4.6]). Patients with EUReop exhibited significantly decreased 1-, 3-, and 5-y patient and graft survival rates. EUReop following LT remains frequent. It is associated with increased 90-d mortality and compromised long-term survival. Patients at risk for EUReop exhibit higher pre-LT acuity and surgical complexity.

Background/Objectives: Portal vein thrombosis (PVT) is prevalent among candidates for liver transplantation (LT) and may serve as a contraindication to transplantation when extensive. Given the rising prevalence of metabolic syndrome, this study aimed to identify clinical factors associated with PVT and evaluate its impact on access to the LT waiting list and the likelihood of undergoing transplantation. Methods: A retrospective cohort of 711 consecutive patients assessed for LT between 2008 and 2020 was included. Data on PVT and various clinical variables were collected, including reasons for exclusion from the waiting list and dropout rates. Multivariable logistic regression models with forward selection and bootstrap were constructed to assess factors associated with PVT, access to the waiting list, and LT. Results: PVT was identified in 11.6% of patients (n = 83), with advanced thrombosis observed in 21% of cases. Obesity emerged as the only independent factor significantly associated with the presence of PVT (p = 0.001, OR 2.619, 95% CI 1.577–4.352). Patients with PVT were more frequently excluded from the waiting list due to clinical contraindications compared to those without PVT (26% vs. 14%, p = 0.04). However, multivariable analysis did not demonstrate an independent association between PVT and access to the waiting list or LT. No significant differences were observed in the reasons for dropout from the waiting list between patients with and without PVT. Conclusions: PVT appears to be associated with the metabolic profile of LT candidates, particularly obesity; however, it does not significantly limit access to LT.

Background: Pediatric liver disease is frequently associated with abnormal conventional coagulation tests; however, prothrombin time expressed as international normalized ratio (PT-INR) incompletely reflect global hemostatic balance. Thrombin generation assay (TGA) provide an integrated assessment of coagulation and may offer complementary information in children with acute liver failure (ALF) and chronic liver disease (CLD). Methods: We enrolled 61 pediatric patients with liver disease (50 CLD, 8 ALF, 3 extrahepatic portal vein obstruction EHPVO) and 51 healthy controls. Platelet-poor plasma was prepared according to international recommendations. Thrombin generation was measured using ST Genesia (STG) with normalization to reference plasma. Group comparisons were performed using non-parametric tests; correlations between PT-INR and thrombin generation parameters were assessed, and principal component analysis (PCA) was used to explore the variance structure of thrombin generation indices and conventional coagulation variables. Results: PT-INR was significantly higher in patients than controls, particularly in ALF. Bleeding events were uncommon. Compared with controls, patients showed reduced levels of fibrinogen and multiple procoagulant/anticoagulant factors (including antithrombin and protein C), with increased factor VIII. Among thrombin generation parameters, the endogenous thrombin potential (ETP) ratio differed significantly across groups (p = 0.001), while correlations between PT-INR and thrombin generation parameters were weak or absent, no significant associations were observed even at higher Pediatric/Model for End-Stage Liver Disease scores. PCA separated thrombin generation indices from PT-INR and conventional coagulation factors, suggesting complementary information. Conclusions: In pediatric liver disease, PT-INR does not reliably reflect global coagulation capacity. Thrombin generation testing provides additional, integrative information on hemostasis and may improve laboratory assessment beyond conventional tests.

Despite the establishment of combined local and systemic therapy as the standard approach for advanced hepatocellular carcinoma (HCC) with portal vein tumor thrombus (PVTT), its efficacy remains constrained by two primary challenges: the immunosuppressive tumor microenvironment (TME) and treatment resistance. Recent research shows that factor Xa (FXa) boosts programmed death-ligand 1 (PD-L1) expression in tumor cells via the proteinase-activated receptor-2 (PAR-2) and signal transducer and activator of transcription 2 (STAT2) pathways, aiding immune evasion. Rivaroxaban, an FXa inhibitor, prevents portal vein thrombosis and disrupts the FXa/PAR-2/PD-L1 axis, restoring T cell function. Based on this mechanism, we propose that incorporating rivaroxaban as a core adjuvant into a long-term, 'local-targeted-immune' multimodal strategy can spatiotemporally reprogram the TME in advanced HCC with PVTT. This approach has the potential to effectively overcome treatment resistance and achieve sustained disease control. The hypothesis is readily testable in clinical trials, and if substantiated, it could establish a new treatment paradigm aimed at improving the prognosis for this high-risk patient population. Furthermore, it would provide a robust theoretical rationale and practical guidance for advancing the treatment of advanced HCC with PVTT.

Abstract Background Vascular complications in liver transplantation are associated with increased postoperative morbidity and mortality. The primary objective of our study was to determine whether postoperative acute rejection in patients undergoing liver transplantation is associated with vascular diameter and anastomotic angle mismatch. Our secondary objective was to evaluate the relationship between the anastomotic angle and hepatic artery and portal vein ratios between donors and recipients, as well as the likelihood of thrombosis in these patients. Materials and Methods Our study involved a retrospective review of 289 adult LTs performed at our center from 2012–2023. Fourteen of these patients were excluded from the study due to the absence of early postoperative computed tomography images in our center's archive, whilst the remaining 275 were included. Results Our evaluation revealed that 80 patients (29.1%) developed biopsy-confirmed acute rejection, and 37 patients (13.5%) experienced hepatic artery thrombosis. Portal vein thrombosis was identified in 43 patients (15.6%). No significant differences in the angles of hepatic artery thrombosis and portal vein thrombosis were observed between patients with and without rejection. Conclusion We believe that diameter discrepancies between the recipient and donor hepatic artery and portal vein, as well as the anastomosis angle, may influence graft vascularity and ultimately lead to rejection in liver transplantation patients. The effects of the anastomosis angle and the significant diameter discrepancy between the hepatic artery and portal vein on rejection should be re-evaluated in larger patient groups at different centers using different surgical approaches.

Abstract Focal nodular hyperplasia (FNH) is a benign lesion occurring in a background of normal liver, often in younger women. It is thought to be secondary to hepatocyte hyperplastic growth response around a localized vascular malformation. While the typical features of FNH are well known, those with atypical appearances could pose a diagnostic challenge. Since FNH is rarely symptomatic and carries no risk for malignant transformation or life-threatening complications, it is essential to distinguish it from other lesions such as hepatocellular adenoma (HCA), hepatocellular carcinoma (HCC), and hypervascular liver metastases to avoid unnecessary interventions. Some of the atypical features to be aware of include presence of microscopic/macroscopic fat, calcification, changes in T2 signal, unusual patterns of hepatobiliary phase contrast uptake, as well as abnormal growth and enhancement. Lesions histologically identical to FNH arising in an abnormal liver are called FNH-like lesions and usually result from conditions affecting the vascular supply of the liver such as Budd-Chiari disease, sinusoidal obstruction syndrome, chronic portal vein thrombosis, and others.

BackgroundSplenic infarction, an uncommon disease, has been demonstrated to be associated with substantial short-term mortality. Given the limited evidence on long-term mortality, this investigation examined the clinical and radiological characteristics of splenic infarction, its long-term prognosis, and predictors of mortality.MethodsThis retrospective cohort study at a tertiary care hospital in Taiwan enrolled adult inpatients with first-episode splenic infarction diagnosed on computed tomography from January 2011 to May 2022. The primary outcome was 1-year all-cause mortality. Kaplan-Meier analysis and multivariate weighted Cox regression were applied for survival analysis.ResultsThe cohort included 304 individuals with an average age of 65.4 years. The mean CCI was 6, and active malignancy was observed in 49%. The estimated 1-year all-cause mortality rate was 61%, and the median survival time was 89 days. Compared with survivors, non-survivors exhibited significantly higher rates of left-sided pleural effusion, peri-splenic ascites, multiple or total infarction, and both portal and splenic vein thrombosis on CT imaging. Older age, active malignancy, decreased hemoglobin levels, low platelet counts, prolonged INR, elevated D-dimer, and peri-splenic ascites were independent predictors of mortality.ConclusionIn splenic infarction, 1-year mortality is notably high. The identified independent prognostic factors included age, malignancy, laboratory findings, and radiologic features. These findings may assist clinicians in early risk stratification for hospitalized patients with splenic infarction.

To evaluate the inter-reader reliability of CT-based measurements of portal vein thrombosis (PVT) to support the development of standardized response criteria endorsed by the Vascular Liver Disease Group (VALDIG) group. In this retrospective bi-centric study, 44 patients with PVT who underwent contrast-enhanced CT (2020-2024) were included. Two independent abdominal radiologists evaluated thrombus characteristics using pre-specified standardized measurements on portal venous phase CT acquisition. For the analysis of the main PVT, quantitative continuous measurement included thrombus length, thickness, and remnant lumen assessment based on diameter (%RLdiam) and surface area (%RLsurf). Categorical classifications were derived using both three-tier and four-tier occlusion scales. Qualitative categorical assessments were performed for involvement of the right and left portal branches, splenic vein, and superior mesenteric vein. Inter-reader agreement was assessed using intraclass correlation coefficients (ICC), weighted and unweighted Cohen's kappa (κ), and Bland Altman plots. Inter-reader agreement for thrombus thickness and length yielded ICC values of 0.92 and 0.84 respectively. Agreement was highest for diameter-based remnant lumen assessment (%RLdiam; ICC = 0.93), outperforming surface-based measurements (%RLsurf; ICC = 0.83). Bland Altman plots confirmed narrower limits of agreement for diameter-based metrics (±22%) compared with surface-based metrics (-32% to +40%). Categorical classification based on diameter showed substantial agreement (weighted κ = 0.71 and 0.78 for three- and four-tier systems, respectively). Semi-quantitative assessment demonstrated substantial concordance, particularly for the right portal branch (κ = 0.77) and superior mesenteric vein (κ = 0.72). Diameter-based quantitative assessment of PVT on CT demonstrates higher inter-reader reproducibility than surface-based measurements. The three-tier diameter-based categorization achieved substantial agreement and aligns with current hepatology guidelines, supporting its applicability in clinical practice and research settings.

Fatigue, depression, and impaired health-related quality of life in patients with vascular liver diseases: a multicentric European study☆.