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Objectives Portal vein tumour thrombus (PVTT)–related symptomatic portal hypertension (SPH) leads to a poor prognosis in hepatocellular carcinoma (HCC) patients. A transjugular intrahepatic portosystemic shunt (TIPS) can effectively relieve SPH but its effect remains unclear in PVTT-related SPH. This study aimed to evaluate the clinical value of the TIPS procedure combined with sequential systemic therapy in advanced HCC patients with PVTT-related SPH. Methods After 1:1 propensity score matching (PSM), this retrospective study analysed 42 patients who underwent TIPS placement plus sequential systemic therapy (group A) and 42 patients who received only symptomatic and supportive treatment (group B). The evaluated outcomes were overall survival (OS) and SPH control rate. Cox proportional hazards regression analysis was used to compare OS in the two groups. Results In group A, the technical success rate of the TIPS procedure was 95.2%, and no severe complications occurred. The rebleeding rates in group A and group B were 5.0% and 73.7%, respectively ( p  &lt; 0.001), and the ascites control rates were 92.0% and 28.0%, respectively ( p  &lt; 0.001). The median OS of group A was significantly better than that of group B (9.6 [95% CI: 7.1, 12.0]  vs.  4.9 [95% CI: 3.9, 5.8], months,  p  &lt; 0.001). Multivariable analysis showed that TIPS plus sequential systemic therapy (hazard ratio [HR] = 5.799; 95% CI: 3.177, 10.585;  p  &lt; 0.001) was an independent prognostic factor related to OS. Additionally, PVTT degree (I+II) ( p  = 0.008), AFP ≤ 400 ng/ml ( p  = 0.003), and Child–Pugh class A ( p  = 0.046) were significant predictors of OS. Conclusion TIPS plus sequential systemic therapy is safe and feasible for treating advanced HCC with tumour thrombus-related SPH. Key Points •  Portal vein tumour thrombus (PVTT) is common in advanced hepatocellular carcinoma (HCC) and transforms compensated portal hypertension into symptomatic portal hypertension (SPH).  •  HCC patients with PVTT-related SPH have a very poor prognosis, and there are no effective treatments recommended by the guidelines.  •  Therefore, a treatment strategy that utilises a transjugular intrahepatic portosystemic shunt (TIPS) to manage SPH combined with sequential systemic therapy in advanced HCC patients is explored in this study for its feasibility and clinical value. This research can fill the gap in current research data to provide clinically meaningful treatment options.

TIPS plus sequential systemic therapy of advanced HCC patients with tumour thrombus-related symptomatic portal hypertension