Validation of A-VENA Criteria in Distinguishing Tumor from Bland Portal Vein Thrombus in Liver Transplant Candidates with Hepatocellular Carcinoma

Background: The A-VENA criteria for distinguishing tumor portal vein thrombus ( PVT) from bland PVT has not been validated. Methods: : Clinical data from January 2018 to December 2021 of Hepatocellular Carcinoma (HCC) with PVT patients who underwent liver transplantation (LT) were retrospectively collected. The diagnostic performance of A-VENA criteria was analyzed by receiver operating characteristic (ROC) curve. Diagnostic factors for tumor PVT were evaluated by multivariable analysis. Modified criteria were proposed based on the results of multivariable analysis. Results: : Of 49 HCC with PVT patients, 26 were pathologically confirmed as tumor PVT and 23 were confirmed as bland PVT. Tumor PVT group has a larger proportion of ‘AFP level >1000 ng/mL’ (61.5% vs 17.4%, P=0.002), ‘enhancement of PVT’ (92.3% vs 13.0%, P<0.001), ‘neovascularity’ (65.4% vs 8.7%, P<0.001), and ‘PVT adjacent to HCC’ (88.5% vs 21.7%, P<0.001). Portal vein expansion was not statically different in two groups (50.0% vs 34.8%, P=0.285). The area under the ROC curve (AUC) was 0.918 for A-VENA criteria (≥3) in distinguishing tumor PVT from bland PVT. Neovascularity (P=0.986) were not independently significant diagnostic factors. The AFP level > 400 ng/mL, enhancement of PVT, and adjacent to HCC were significant in multivariable analysis. The presence of ≥2 criteria of the three (AEA criteria) best characterized tumor PVT with an AUC of 0.978, 100% sensitivity, 95.7% specificity, 96.3% positive predictive value, and 100% negative predictive value. Conclusions: : A-VENA criteria could accurately distinguish tumor PVT from bland PVT in LT candidates. Proposed AEA criteria (the presence of at least 2 of the following: AFP >400 ng/dL, PVT enhancement, and adjacent to HCC) is an alternative tool for the diagnosis of tumor PVT.