**8. The prognostic value of elastography for the prediction of clinical outcomes (decompensation; HCC) in patients with HCV-related cACLD who achieved sustained virological response**

In HCV-infected patients, the risk of all-cause mortality and the incidence of HCC diminished in subjects who achieved SVR after interferon-based antiviral therapy, regardless of the grade of fibrosis [96, 97]. In addition, the introduction of novel highly efficient DAAs improved the capability of decreasing the HCC risk, even among patients with advanced liver disease [50]. Nonetheless, a relevant risk of 1.5% remains, requiring proper and cost-effective surveillance methods for these patients [98, 99]. Evidence shows that clinically significant portal hypertension (CSPH), defined as hepatic venous pressure gradient (HVPG) ≥10 mmHg, is the strongest predictor for hepatic decompensation [6]. For these patients, compensated advanced CLD (cACLD) is the proposed term by the Baveno VI consensus [100]. However, HVPG is an invasive and expensive method, requiring reliable noninvasive alternatives [50].

Being a noninvasive, low-cost, and easy to perform method, VCTE turned out to be an outstanding diagnostic instrument for CSPH, with a hierarchical summary ROC of 0.93 [101]. A recent multicenter study of 5648 patients, found that lowering the dual-threshold to <7 kPa and > 12 kPa, provided excellent Se of 91% for excluding and great Sp of 92% for diagnosing cACLD, respectively [100]. In addition, elastography might enable the dynamic appraisal of the HCC risk, especially before and after antiviral treatment. Several studies aimed to elucidate whether VCTE, p-SWE, and 2D-SWE may facilitate HCC surveillance in HCV-infected patients [102–105]. A recent meta-analysis, comprising 3398 patients, found a pooled HR for HCC development of 3.43 (95% CI, 1.63–7.19) between positive and negative LSM, indicating that

#### *Noninvasive Assessment of HCV Patients Using Ultrasound Elastography DOI: http://dx.doi.org/10.5772/intechopen.102294*

VCTE is a trustworthy procedure for HCC prediction in CHC patients treated with DAAs [106]. In a multicenter cohort study, Alonso et al. [107] provided two easy and broadly applicable models for the estimation of HCC risk after SVR. Their model, including baseline albumin (≥ or < 4.2 g/dl), baseline LS (> or ≤ 17.3 KPa), and LS after 1 year (≥ or < 25.5%), increased HCC surveillance efforts (Harrell's C: 0.77). In 2018, Ioannou et al. [108] internally validated models that calculate the HCC risk following antiviral treatment. However, current EASL clinical practice guidelines recommend that patients with cACLD before antiviral therapy should be continuously supervised for HCC and portal hypertensions, regardless of measurement values of noninvasive tests post-SVR.
