Beyond the hype: understanding the limits of perceived benefits in endoscopic ultrasound-guided portal pressure gradient measurement

Martínez-Moreno et al. [1] examined the correlation between endoscopic ultrasound-guided portal pressure gradient (EUS-PPG) and hepatic venous portal gradient (HVPG) measurements, but the manuscript lacks strong evidence to support its conclusions. Accurate HVPG measurement, critical for risk prediction, requires strict standardization, which this study fails to achieve. Variations included inconsistent use of sedation and general anesthesia, nonstandardization, suboptimal velocity of tracings, and reliance on single observations. Deep sedation during EUS-PPG reduces accuracy, with patients with mild portal hypertension showing 2% variation but greater dispersion above 12 mmHg [2].

Gradients were inconsistently calculated using hepatic vein or inferior vena cava, and measurements were performed under different conditions on separate days, undermining comparability. The Bland–Altman plot reveals wide limits of agreement (mean difference 1.96 SD), even exceeding the critical 5 mmHg threshold and indicating poor concordance. A significant proportion of patients likely have >10% discrepancy between EUS-PPG and HVPG; accurate measurements are vital, as a 10% variation (e.g. 1.5 mmHg difference in an HVPG of 11 mmHg) can alter the diagnosis of clinically significant portal hypertension, leading to misclassification and critical clinical consequences [3]. Furthermore, in secondary prophylaxis, response to nonselective beta blockers (20% decrease) in a hypothetical patient with a baseline of 16 mmHg is equal to 3 mmHg variation, which falls within procedural error.

Additionally, studying only patients with decompensated cirrhosis limits the clinical utility of the findings and applicability. Patients with primary sclerosing cholangitis or metabolic-associated fatty liver disease, who are known to have presinusoidal hypertension, were not analyzed separately, and the reported concordance is surprising and inconsistent with prior evidence [4]. Finally, the 6% rate of serious adverse events highlights the higher risk of EUS-PPG versus HVPG, which is safe even in coagulopathy, requires no sedation or antibiotics, and can be performed as an outpatient procedure [5]. Thus, comprehensive informed consent is essential to justify EUS-PPG. Are we ready to adopt a more invasive, riskier, and costlier technique in an era focused on developing noninvasive methods?

Publication History

Article published online:
28 May 2025

• References

• 1 Martínez-Moreno B, Martínez Martínez J, Herrera I. et al. Correlation of endoscopic ultrasound-guided portal pressure gradient measurements with hepatic venous pressure gradient: a prospective study. Endoscopy 2025; 57: 62-67
• 2 Reverter E, Blasi A, Abraldes JG. et al. Impact of deep sedation on the accuracy of hepatic and portal venous pressure measurements in patients with cirrhosis. Liver Int 2014; 34: 16-25
• 3 Silva-Junior G, Baiges A, Turon F. et al. The prognostic value of hepatic venous pressure gradient in patients with cirrhosis is highly dependent on the accuracy of the technique. Hepatology 2015; 62: 1584-1592
• 4 Ferrusquía-Acosta J, Bassegoda O, Turco L. et al. Agreement between wedged hepatic venous pressure and portal pressure in non-alcoholic steatohepatitis-related cirrhosis. J Hepatol 2021; 74: 811-818
• 5 Ferral H, Schepis F, Gaba RC. et al. Endovascular assessment of liver hemodynamics in patients with cirrhosis complicated by portal hypertension. J Vasc Interv Radiol 2023; 34: 327-336