Development and validation of a nomogram predicting rebleeding in cirrhotic patients with patent transjugular intrahepatic portosystemic shunt

Abstract

BACKGROUND

Even with stent patency following transjugular intrahepatic portosystemic shunt (TIPS) placement, some patients still experience recurrent variceal bleeding.

AIM

To identify risk factors and develop a predictive model for rebleeding in patients with patent TIPS stents.

METHODS

Cirrhotic patients (n = 647) undergoing TIPS (2010-2024) were retrospectively analyzed and grouped by rebleeding status. Propensity score matching (1:3) was performed for age, sex, and model for end-stage liver disease score. Independent predictors identified via univariate and multivariate logistic regression were used to construct a nomogram. The model was internally validated using bootstrapping and evaluated via area under the receiver operating characteristic curve (AUC), calibration curves, and decision curve analysis.

RESULTS

Of the 73 patients with rebleeding following patent TIPS placement, variceal rebleeding was the primary etiology (n = 45). Univariate analysis revealed that platelet count (PLT), pre-procedural pressure gradient (pre-PPG), spleen dimensions (length, width, volume), and splenic vein parameters (diameter, flow) were significantly associated with rebleeding (all P < 0.001). Multivariate regression identified PLT [odds ratio (OR) = 0.980, 95% confidence interval (CI): 0.963-0.996], spleen length (OR = 1.177, 95%CI: 1.002-1.381), spleen width (OR = 1.425, 95%CI: 1.088-1.866), pre-PPG (OR = 1.182, 95%CI: 1.067-1.309), and splenic vein diameter (OR = 1.501, 95%CI: 1.074-2.097) as independent predictors (all P < 0.05). The nomogram exhibited strong discrimination (AUC = 0.883, 95%CI: 0.831-0.936) and favorable calibration (mean absolute error = 0.046). Decision curve analysis confirmed a positive clinical net benefit.

CONCLUSION

The nomogram developed in this study enables the precise prediction of post-TIPS placement rebleeding risk, assisting clinicians in individualized risk stratification and postoperative therapeutic strategies.

Keywords: Transjugular intrahepatic portosystemic shunt; Oesophagogastric variceal rebleeding; Nomogram; Predictive model; Portal hypertension; Stent patency; Propensity score matching

Core Tip: Rebleeding following technically patent transjugular intrahepatic portosystemic shunt (TIPS) placement remains a significant clinical challenge, especially with the use of reduced-diameter stents aimed at mitigating overt hepatic encephalopathy. Although smaller stents decrease procedure-related complications, they may increase the risk of insufficient shunt flow and subsequent variceal rebleeding. This study identified patients experiencing rebleeding despite shunt patency and evaluated pre-procedural factors associated with this adverse outcome. By establishing a predictive nomogram, this research provides a practical tool for screening high-risk individuals, ultimately supporting individualized clinical decision-making and the selection of optimal TIPS diameters for cirrhotic patients.