ObjectiveTo investigate the risk factors affecting severe postoperative complications (Clavien-Dindo classification Ⅲa or higher) in patients with end-stage hepatic alveolar echinococcosis (HAE) underwent ex vivo liver resection and autotransplantation (ELRA), and to develop a nomogram prediction model. MethodsThe clinical data of end-stage HAE patients who underwent ELRA at the West China Hospital of Sichuan University from January 2014 to June 2024 were retrospectively analyzed. The logistic regression was used to analyze the risk factors affecting severe postoperative complications. A nomogram prediction model was established basing on LASSO regression and its efficiency was evaluated using receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis. Simultaneously, a generalized linear model regression was used to explore the preoperative risk factors affecting the total surgery time. Test level was α=0.05. ResultsA total of 132 end-stage HAE patients who underwent ELRA were included. The severe postoperative complications occurred in 47 (35.6%) patients. The multivariate logistic analysis results showed that the patients with invasion of the main trunk of the portal vein or the first branch of the contralateral portal vein (type P2) had a higher risk of severe postoperative complications compared to those with invasion of the first branch of the ipsilateral portal vein (type P1) [odds ratio (OR) and 95% confidence interval (CI)=8.24 (1.53, 44.34), P=0.014], the patients with albumin bilirubin index (ALBI) grade 1 had a lower risk of severe postoperative complications compared to those with grade 2 or higher [OR(95%CI)=0.26(0.08, 0.83), P=0.023]. Additionally, an increased total surgery time or the autologous blood reinfusion was associated with an increased risk of severe postoperative complications [OR(95%CI)=1.01(1.00, 1.01), P=0.009; OR(95%CI)=1.00(1.00, 1.00), P=0.043]. The nomogram prediction model constructed with two risk factors, ALBI grade and total surgery time, selected by LASSO regression, showed a good discrimination for the occurrence of severe complications after ELRA [area under the ROC curve (95%CI) of 0.717 (0.625, 0.808)]. The generalized linear regression model analysis identified the invasion of the portal vein to extent type P2 and more distant contralateral second portal vein branch invasion (type P3), as well as the presence of distant metastasis, as risk factors affecting total surgery time [β (95%CI) for type P2/type P1=110.26 (52.94, 167.58), P<0.001; β (95%CI) for type P3/type P1=109.25 (50.99, 167.52), P<0.001; β (95%CI) for distant metastasis present/absent=61.22 (4.86, 117.58), P=0.035]. ConclusionsFrom the analysis results of this study, for the end-stage HAE patients with portal vein invasion degree type P2, ALBI grade 2 or above, longer total surgery time, and more autologous blood transfusion need to be closely monitored. Preoperative strict evaluation of the first hepatic portal invasion and distant metastasis is necessary to reduce the risk of severe complications after ELRA. The nomogram prediction model constructed based on ABLI grade and total surgery time in this study demonstrates a good predictive performance for severe postoperative complications, which can provide a reference for clinical intervention decision-making.