Deep Learning‐Enhanced CTA for Noninvasive Prediction of First Variceal Haemorrhage in Cirrhosis: A Multi‐Centre Study

ABSTRACT Background and Aims The first variceal haemorrhage (FVH) is a life‐threatening complication of liver cirrhosis that requires timely intervention; however, noninvasive tools for accurately predicting FVH remain limited. This study aimed to develop noninvasive, deep learning‐enhanced computed tomographic angiography (CTA) models for early and accurate FVH prediction. Methods This multi‐centre retrospective study included 184 cirrhotic patients (FVH: n = 107, non‐FVH: n = 77) enrolled from December 2014 to May 2022. Patients were randomly divided (7:3) into training and validation cohorts. CTA and clinical data were collected and analysed. A novel Vision‐Transformer (ViT) network, combined with reinforcement learning (RL), was applied to CTA images to predict FVH and was compared with convolutional neural networks (CNNs). Models were evaluated using the area under the receiver operating characteristic curve (AUC) and decision curve analysis (DCA), and feature importance was determined from model coefficients and gradients. Results The ViT + RL* model demonstrated superior diagnostic performance, achieving an AUC of 0.985 (95% CI, 0.955–1.0) in the validation cohort and 0.956 (95% CI, 0.919–0.988) in the training cohort, outperforming traditional CNNs. DCA and the area under the curve confirmed the enhanced clinical utility of the ViT + RL* model compared to CNNs; the ViT + RL* model highlighted critical regions in the liver, spleen, oesophageal lumen, and abdominal vessels. Meanwhile, clinical data identified creatinine and prothrombin time as potential predictive factors, with moderate predictive performance. Conclusions The novel deep learning‐enhanced CTA models offer a robust, non‐invasive method for predicting FVH, with the ViT + RL* model demonstrating excellent efficacy; thus providing a valuable tool for early risk stratification in cirrhotic patients.