A retrospective study included 239 cirrhotic patients undergoing TIPS and investigated the predictive value of the ratio of visceral fat to subcutaneous fat area (V/S ratio) for post-TIPS overt hepatic encephalopathy (OHE) at 1 year and transplant-free survival (TFS) at 2 years. ROC analysis showed significant predictive ability of V/S ratio and VFA for 1-year OHE with AUROC 0.817 (p < 0.001). In multivariate Cox regression, risk factors for 1-year OHE were age, V/S ratio, creatinine, and combined sarcopenia with myosteatosis. A high V/S ratio was associated with a 1.75-fold risk of 1-year OHE (HR 1.748, 95% CI 1.438–2.124, p < 0.001). An equally high V/S ratio increased the risk of death or liver transplantation 1.55-fold (HR 1.547). Preoperative assessment of the V/S ratio serves to predict OHE and TFS after TIPS.[3]