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 In 4 patients anticoagulants were withdrawn before the procedure.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.
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.
Video 1 EUS-guided PPG measurement: safety and technical aspects.
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
Acknowledgments
This paper is dedicated to the memory of Dr. Francisco Pellicer-Bautista, MD, PhD.
Footnotes
Competing interests Rafael Romero-Castro has received speaker’s fees from Cook Medical since May 31, 2023. The remaining authors declare that they have no conflict of interest.
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