Utility of Baveno VII criteria for endoscopy risk stratification prior to systemic therapy in unresectable hepatocellular carcinoma: A real-world Veterans Health Administration experience.

Abstract

e23388 Background: Patients with unresectable hepatocellular carcinoma (HCC) are at risk for gastroesophageal varices and bleeding. First-line atezolizumab–bevacizumab therapy requires baseline esophagogastroduodenoscopy (EGD) to exclude high-risk varices, which may delay treatment and increase procedural burden, particularly in resource-limited settings. The Baveno VII criteria noninvasively identify cirrhotic patients at low risk for clinically significant portal hypertension (CSPH) using platelet count and liver stiffness. We hypothesized that Baveno VII criteria could risk-stratify unresectable HCC patients for baseline EGD urgency. Methods: We conducted a retrospective cohort study of adults with unresectable HCC treated at a single Veterans Health Administration center from 2020–2025. Baseline characteristics and events were sourced from the electronic health record. Cirrhosis severity was stratified using Baveno VII criteria as low-risk CSPH, probable CSPH, or definite CSPH. The primary endpoint was variceal bleeding requiring intervention. Secondary endpoints included overall bleeding events and CTCAE-graded bleeding severity. Associations were analyzed using chi-square or Fisher’s exact tests. Results: Ninety-three patients were included. The primary endpoint occurred in three patients (3.2%), all with advanced cirrhosis, including probable CSPH (n = 1) or decompensated cirrhosis (n = 2). No variceal bleeding occurred among patients without cirrhosis or those classified as low risk for CSPH. Cirrhosis severity was not significantly associated with the primary endpoint (p = 0.34). Of the thirty-three patients (35%) who did not undergo baseline EGD, seven experienced a bleeding event with no significant association (p = 0.89). Most of the total nineteen bleeding events were non-variceal and low-grade. Higher-grade bleeding occurred in patients with probable CSPH or decompensated cirrhosis. Race was significantly associated with the primary endpoint (p < 0.001). Conclusions: In this cohort developed from real-world data, variceal bleeding requiring intervention during systemic therapy was uncommon and limited to patients with advanced cirrhosis. No bleeding occurred in patients without cirrhosis or those classified as low risk by Baveno VII criteria. These findings suggest Baveno VII criteria may support a more individualized, resource-conscious approach to baseline EGD before systemic therapy. Prospective multicenter validation is needed. Association between baseline characteristics and bleeding events. Variceal Bleed (p-value) Any Bleed Bleed Severity Age 0.70 0.24 0.60 Race <0.001 0.33 0.19 Child-Pugh 0.23 0.03 0.40 Baveno VII/Cirrhosis Severity 0.34 0.88 0.09 Beta Blocker Use 0.90 0.80 0.67 First Line Therapy Receipt 0.22 0.57 0.24 EGD Receipt 0.93 0.89 0.20