Reliability of Endoscopic Ultrasound compared to Transjugular Measurements of Portal Pressure Gradient in Patients with Clinically Significant Portal Hypertension Undergoing TIPS – a pilot study

Aims Endoscopic ultrasound (EUS) has emerged as a valuable tool for assessing portal hypertension (PH). No prior comparative assessment of direct portal pressure gradient (PPG) as measured by EUS versus the transjugular route exists. Our study aimed to compare the values of EUS-PPG and transjugular PPG in patients with clinical significant portal hypertension (CSPH) scheduled for transjugular intrahepatic portosystemic shunt (TIPS).

Methods Patients scheduled for TIPS were included. Exclusion criteria ere platelet<50,000/µL and an INR>2.5. EUS was performed using a 22-gauge FNA needle attached to a central venous pressure measurement monitor. Three measures were taken and the mean was noted. TIPS placement was performed as standard of care. All patients underwent indirect hepatic venous pressure gradient (HVPG) and direct PPG measurements through the transjugular approach under fluoroscopic guidance.

Results We prospectively enrolled 23 patients between January 2023 and October 2024, with an average age of 50±14 years. The male-to-female ratio was 4.2:1. The causes of PH were porto-sinusoidal vascular disease (n=2, 8.69%), alcoholic cirrhosis (n=17, 73.9%), viral cirrhosis (n=2, 8.69%), metabolic cirrhosis (n=1, 4.7%) and Budd-Chiari (n=1, 4,7%). Among patients with cirrhosis, 50% were classified as Child-Pugh class B or C. The mean INR was 1.41, and the mean platelet count was 122,000/µL. EUS-PPG was technically successful in 23 patients (92%), with two failures attributed to either obesity or significant ascites, which impeded deep needle advancement into the portal vein (PV). Transjugular PPG measurements were successful in all 23 cases (100%). Variability between the three measurements by EUS was 5,8%±6% (IQR, 0-12%; range, 0%-18,3%) for hepatic venous pressure and 4,3%±5,3% (IQR, 0-6,8%; range, 0%-10,7%) for portal venous pressure. The mean EUS-PPG and transjugular PPG correlated very strong (13.5±3.7 mmHg versus 14.6±4.2 mmHg, r=0.81, p<0.01). In three cases, differences of pressure in PV and IVC vein measured by each method were greater than 5mmHg but the difference remained constant within measurement and the final PPG was similar. Clinically significant portal hypertension (PPG>10mmHg) was correctly assessed in 100% of cases using both methods. One adverse effect was reported and consisted of singular episode of high fever, 3h after the procedure.

Conclusions The direct measurements of PH by transjugular route or EUS are comparable. EUS-PPG measurement with 22G needle proved to be an accurate and safe technique and proves reliable in correctly diagnosing CSPH. We report a slightly lower correlation between IVC measurements, but the final gradient was similar and no difference in diagnosing CSPH was noted. Further studies on EUS measurement of IVC pressure are needed.

Conflicts of Interest

Authors do not have any conflict of interest to disclose.

Publication History

Article published online:
27 March 2025