Role of spleen stiffness measurement by vibration-controlled transient elastography at 100 Hz in guiding invasive hemodynamic reassessments after underdilated transjugular intrahepatic portosystemic shunt (TIPS)

Background: Transjugular intrahepatic portosystemic shunt (TIPS) is a well-established intervention for the secondary prophylaxis of variceal bleeding (VB) in patients with cirrhosis. To reduce the risk of shunt-related complications such as hepatic encephalopathy and cardiac decompensation, an “under-dilation” strategy involving a stent-graft dilated to a diameter <8 mm is currently often employed. In this setting, post-TIPS hemodynamic management remains challenging, as the portocaval pressure gradient (PCPG) measured at the end of the procedure can be unreliable. Increasing evidence suggests that spleen stiffness measurement (SSM) via vibration-controlled transient elastography (VCTE), particularly with a spleen-dedicated 100 Hz probe, may serve as a non-invasive surrogate for the hepatic venous pressure gradient and portal hypertension. Aim: This prospective monocentric study aimed to investigate the correlation between SSM and PCPG in patients with cirrhosis undergoing under-dilated TIPS for secondary prophylaxis of VB and to assess the diagnostic accuracy of post-TIPS SSM in identifying an adequate hemodynamic response (PCPG <12 mmHg) in clinically stable patients. Methods: A total of 53 patients were enrolled between January 2023 and January 2025. Inclusion criteria required a diagnosis of cirrhosis and an indication for TIPS as secondary VB prophylaxis. Patients with acute-on-chronic liver failure, portal vein thrombosis, or previous splenectomy were excluded. Hemodynamic assessment and SSM were conducted before, immediately after, and one-month post-TIPS. The TIPS was initially dilated to 5 mm and selectively expanded to 6 or 7 mm based on clinical and procedural parameters. CT-derived spleen volumetry and right heart catheterization were also performed. Results: All patients received a VIATORR® CX stent-graft with a median dilation diameter of 6 mm. The median age was 62 years, 64% were male, and liver function was overall well-preserved (median Child-Pugh score 7; MELD-Na 12). Baseline bipolar spleen diameter exceeded 13 cm in 93% of patients. SSM showed a significant decline over time: from 73.6 kPa at baseline to 50.5 kPa post-TIPS, and 42.2 kPa at one-month. Concurrently, PCPG decreased from 22 mmHg to 13 mmHg post-TIPS and 11 mmHg at one-month reassessment. SSM and PCPG were positively correlated at all timepoints (R = 0.66 overall; p value <0.001). A 36 kPa SSM cut-off one-month post-TIPS identified patients with PCPG <12 mmHg with 96% sensitivity and 94% negative predictive value (AUC 0.862). Correlation was particularly strong in patients with hyperdynamic circulation. Conclusion: SSM using a spleen-dedicated VCTE probe is a promising, non-invasive tool for monitoring PCPG changes following TIPS and reliably identifies an adequate hemodynamic response at one-month. This method could improve post-TIPS management and facilitate individual risk stratification.