Anatomical Architectonics of Portacaval Fibrous Connections in the Cirrhotic Liver and Their Clinical Potential in the Management of Portal Hypertension

Abstract

Introduction: During the course of liver cirrhosis, portal hypertension and subsequent variceal hemorrhage represent severe complications with high mortality risks, commonly managed by transjugular intrahepatic portosystemic shunt (TIPS), which, however, is frequently associated with stent thrombosis and migration. The aim of this study was to evaluate the anatomical characteristics and structural stability of portacaval fibrous connections (PCFCs) using normal and cirrhotic liver tissue and to determine their potential utility in an alternative, minimally invasive endovascular treatment for portal hypertension. Methods: The study integrated complex morphological, histological (Masson's trichrome and Picrosirius red staining), and topographic-anatomical micropreparation methods on autoptic and biopsied specimens of normal and cirrhotic livers, specifically focusing on segments I, II, and III. Results: Morphological analysis demonstrated that PCFCs constitute permanent and predictable structures within the intrahepatic connective tissue framework, exhibiting the highest density in segments I-III. Under the conditions of extracellular matrix remodeling during liver cirrhosis, the fibrous bridges within the PCFC zones thicken significantly and undergo hypertrophy, which markedly increases their mechanical stability. Based on these findings, a novel theoretical model for endovascular intervention was developed, proposing targeted perforation of the portal and hepatic vein branches directly within the projection of natural PCFC bridges, completely avoiding artificial stent implantation. Conclusion: that despite cirrhotic transformation, PCFCs maintain topographic regularity, and their increased mechanical strength provides a unique opportunity for creating a stent-free portosystemic shunt, thereby minimizing parenchymal traumatization and preventing the specific complications of traditional TIPS. For clinical translation, it is recommended to integrate high-resolution 3D radiological imaging in the preoperative phase and to develop corresponding microsurgical instruments.