Transjugular intrahepatic portosystemic shunt (TIPS) creation is a validated procedure for the management of gastroesophageal variceal bleeding and refractory ascites due to portal hypertension in patients with cirrhosis. Sarcopenia, characterized by a decline in skeletal muscle mass, strength, and function [1] is commonly seen in cirrhosis, and represents a major source of morbidity and mortality. Using the skeletal muscle index (SMI), defined as total skeletal muscle mass in kilograms normalized by the square of height in meters, in patients with cirrhosis awaiting liver transplantation, a value below 50.0 cm2/m2 in men and 42.0 cm2/m2 in women was observed to be meaningful in predicting both waitlist mortality and delisting [2].

Recently, there has been increasing awareness and observation of changes in body composition after TIPS creation that may favorably impact clinical outcomes. This represents a very unique clinical opportunity, as most conditions associated with sarcopenia demonstrate an irreversible and unrelenting pattern [3, 4, 5]. Some studies indicated that sarcopenia before TIPS creation is strongly associated with increased morbidity and mortality following TIPS creation [5, 6, 7, 8] and multiple other studies have demonstrated that patients with sarcopenia benefit more from TIPS than non-sarcopenic patients, with reports consistently showing increased muscle mass following TIPS creation [9, 10, 11, 12, 13, 14]. Reversal of sarcopenia after TIPS creation in observational studies has consistently been noted to positively impact morbidity and mortality [9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23].

Biomarker parameters that can improve patient selection and identify early responses in body composition after TIPS creation represent a gap in current knowledge. Additional unknowns are the underlying physiologic and biologic mechanisms driving this unique change in body composition. This systematic review aims to identify the currently observed imaging biomarkers used for assessment of changes in body composition after TIPS creation and to clarify the current state of knowledge on the impact on morbidity and mortality in cirrhosis.