Portal Vein Diameter on Routine Clinical CT: Establishing Normals and Disease Associations.

Purpose: Portal hypertension, a major complication of chronic liver disease, leads to significant morbidity and mortality. While portal vein diameter measured on imaging has long been proposed as a non-invasive marker of portal hypertension, normative CT-based reference values and population-level associations remain incompletely characterized. Here, we aim to define contemporary reference values for portal vein diameter on clinically obtained CT and evaluate its associations with demographic, clinical, and imaging factors, as well as its diagnostic performance for portal hypertension. Methods: We conducted a retrospective analysis of 20,225 clinically obtained CT scans at a single academic medical center. The main portal vein was automatically segmented using Total Segmentator, and maximum diameter extracted using the Vascular Modeling Toolkit. Associations with demographic and imaging factors were evaluated using linear mixed-effects models; prevalent liver disease and portal hypertension using logistic regression; risk of incident ascites and esophageal varices among participants with liver disease using Cox regression; and invasive hepatic venous pressures using correlation analysis and linear regression. Results: The mean portal vein diameter was 12.4 mm (95% CI, 12.37-12.45). Larger diameter was independently associated with male sex (+1.4 mm), higher BMI (+0.11 mm/kg/m Conclusion: In this large, EHR-linked imaging cohort, the mean portal vein diameter on CT was 12.4 mm and varied with demographic and imaging factors. Larger diameter was associated with liver disease, portal hypertension, and subsequent development of varices and ascites, supporting use of portal vein diameter as a pragmatic screening or enrichment tool within multimodal clinical frameworks.