Ultra‐Large Spontaneous Portosystemic Shunt is Correlated With a Higher Hepatic Venous Pressure Gradient and Increased Risk of Hepatic Encephalopathy

BACKGROUND: 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. METHODS: 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. RESULTS: 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). CONCLUSIONS: 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.