The hepatic venous pressure gradient obtained by interventional radiology is the current
gold-standard, indirect method for quantifying the degree of portal hypertension [1]. Direct measurement of the portal pressure gradient (PPG) under endoscopic ultrasound
(EUS) guidance using 25-gauge [2]
[3] and 22-gauge needles has been reported [4].
We here report on EUS-guided PPG in 21 patients, with successful assessment in 19
(90 %) of these patients, using a dedicated 25-gauge needle (EchoTip Insight; Cook,
Limerick, Ireland). Mean procedure time was 24 ± 12 minutes. In 4 patients anticoagulants
were withdrawn before the procedure. One patient had transient epigastric pain 3 days
after the procedure, which had been combined with bilobar liver biopsy; hospital admission
was not required. No other adverse events were registered either immediately or 1
month later.
Technical difficulties encountered are demonstrated in [Video 1]. In 2 cases (10 %), EUS-guided measurement of PPG failed because of exacerbated
breathing movements and to unreliability of the pressure measurements, probably due
to excessive bending of the echoendoscope and needle ([Fig. 1]) and to use of the elevator and the up-and-down wheel. Thinner 25-gauge needles
offer more flexibility and penetration ability than 22-gauge needles [5]. Occasionally, when puncturing the portal vein, even with a dedicated 25-gauge needle,
the liver parenchyma is pushed away and the ultrasonographic window is momentarily
lost. In such a case, the needle could puncture the hepatic artery. In 1 patient the
25-gauge needle passed close to the hepatic artery ([Fig. 2]). We experienced difficulty in puncturing the wall of the hepatic vein in 1 case
and the portal vein in 2 cases, having to traverse these vessels ([Fig. 3], [Fig. 4]) and retrieve the needle.
Video 1 EUS-guided PPG measurement: safety and technical aspects.
Fig. 1 Bending of the needle displayed by endoscopic ultrasonography.
Fig. 2 Endosonographic view of the dedicated 25-gauge needle traversing the hepatic vein.
Fig. 3 The left intrahepatic portal vein branch is traversed with a dedicated 25-gauge needle.
Fig. 4 Endosonographic view of the dedicated 25-gauge needle inserted into the portal vein
in very close proximity to the hepatic artery.
[Table 1] shows the theoretical advantages of 25-gauge needles over 22-gauge needles in EUS-guided
PPG measurement. To obtain reliable readings, forcing the elevator and the up-and-down
wheel of the echoendoscope should be avoided.
Table 1
Possible pros and cons of dedicated 25-gauge needles vs. 22-gauge needles in endoscopic
ultrasound-guided portal pressure gradient measurement
|
25-Gauge needles
|
22-Gauge needles
|
|
More flexibility and penetration ability
|
Less flexibility and penetration ability
|
|
Lower probability of adverse events
|
Higher probability of adverse events
|
|
Puncture of vessels easier
|
Puncture of vessels more cumbersome
|
|
Pressure measurement in narrow vessels more reliable
|
Pressure measure in narrow vessels less reliable with the needle in contact with the
wall
|
In reporting our experience here, our aim is to help make the procedure of EUS-guided
PPG measurement as safe and accurate as possible.
Endoscopy_UCTN_Code_TTT_1AS_2AG
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