Endoscopic Ultrasound-Guided Portosystemic Pressure Gradient Measurement vs. Transjugular Balloon Occlusion Measurement (ENCOUNTER): A Multicenter EU Study

Aims Patients with cirrhosis and clinically significant portal hypertension are at elevated risk for hepatic decompensation and liver-related mortality. The hepatic venous pressure gradient (HVPG) is the accepted method for quantifying portal hypertension, providing valuable risk assessment and treatment guidance for individual patients. However, HVPG has limitations due to its indirect measurement approach and limited availability. Endoscopic ultrasound-guided portal pressure gradient (EUS-PPG) offers an alternative using EUS-guided venipuncture to directly measure hepatic and portal venous pressures. The ENCOUNTER study is the first to compare EUS-PPG to HVPG in the same patient, simultaneously.

Methods This prospective, international, bicentric study included patients referred for HVPG measurement or transjugular intrahepatic portosystemic shunt (TIPS) placement at the University Hospital of Leuven (Belgium) and Hospital Clinic Barcelona (Spain). Patients underwent standard-of-care HVPG, followed by simultaneous HVPG and EUS-PPG measurements under propofol general anesthesia. Adverse events were monitored for up to 30 days post-procedure.

Results From a total of 35 patients, 14 had to be excluded because of intrahepatic venovenous shunts, hemodynamic instability and/or inadequate HVPG tracings. The final analysis included 21 patients with cirrhosis undergoing simultaneous HVPG and EUS-PPG of whom 15 received TIPS. All patients had underlying cirrhosis, which was predominantly alcohol-related (57.1%). Mean MELD score was 10.8±4.2 and most patients had Child-Pugh B cirrhosis. Mean HVPG and EUS-PPG under general anesthesia were comparable (11.9±5.2 vs. 10.9±5.6 mmHg, p=0.2332) and correlated with one another (r=0.74, p=0.0001). The individual components of the gradients (portal vein and hepatic vein) equally showed a good correlation (portal vein: r=0.85, p<0.0001; hepatic vein: r=0.72, p=0.0003). In patients receiving TIPS, direct transjugular portal pressure measurements demonstrated an excellent correlation with EUS-guided portal pressures (r=0.91, p<0.0001). Technical success was achieved in all cases, with no adverse events associated with the EUS-PPG procedure.

Conclusions EUS-PPG is a reliable and safe alternative tool to HVPG for the direct measurement of portal pressure, and yields comparable results to HVPG when measured simultaneously in the same patients and under the same conditions. This technique could be particularly valuable in situations where non-invasive tests are unable to confirm or rule out portal hypertension, in conditions where HVPG underestimates portal hypertension, or when used alongside other endoscopic or endosonographic procedures. Future research should explore the impact of anesthesia on EUS-PPG, its role in monitoring therapeutic responses to beta-blocker therapy, as well as its cost-effectiveness.

 

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Conflicts of Interest

WL has consultancy agreements with Pentax Medical, Boston Scientific and CSL Behring. AG has been awarded a grant from Cook Medical. AB has received speaking fees from Gore. MB serves as a consultant for Boston Scientific, Cook Medical, Pentax Medical, EcoLab and Interscope and has received grants for industry and investigator-initiated research from Boston Scientific, Cook Medical, Pentax Medical, InterScope and Mylan. JCGP serves as an advisor for GSK, has received speaker fees from GORE and Cook Medical, and has been awarded grants from Mallinckrodt, Cook Medical, and AstraZeneca. SV holds the Boston Scientific Chair in Interventional Endoscopy as well as the Cook chair for the study of portal pressure measurement, and holds consultancy agreements with Cook, Pentax and Olympus. All other authors declare no conflicts of interest relevant to this work.

Publication History

Article published online:
27 March 2025