Correlation of pressure gradient in three hepatic veins with portal pressure gradient

BACKGROUND The liver is one of the most important organs in the human body,with functions such as detoxification,digestion,and blood coagulation.In terms of vascular anatomy,the liver is divided into the left and the right liver by the main portal vein,and there are three hepatic efferent veins(right,middle,and left)and two portal branches.Patients with impaired liver function have increased intrahepatic vascular resistance and splanchnic vasodilation,which may lead to an increase in the portal pressure gradient(PPG)and cause portal hypertension(PHT).In order to measure the increased pressure gradient of portal vein,the hepatic venous pressure gradient(HVPG)can be measured to reflect it in clinical practice.The accuracy of PPG measurements is directly related to patient prognosis.AIM To analyze the correlation between HVPG of three hepatic veins and PPG in patients with PHT.METHODS From January 2017 to December 2019,102 patients with PHT who met the inclusion criteria were evaluated during the transjugular intrahepatic portosystemic shunt procedure and analyzed.RESULTS The mean HVPG of the middle hepatic vein was 17.47±10.25 mmHg,and the mean HVPG of the right and left hepatic veins was 16.34±7.60 and 16.52±8.15 mmHg,respectively.The average PPG was 26.03±9.24 mmHg.The correlation coefficient and coefficient of determination of the right hepatic vein,middle hepatic vein,and left hepatic vein were 0.15 and 0.02(P=0.164);0.25 and 0.05(P=0.013);and 0.14 and 0.02(P=0.013),respectively.The mean wedged hepatic vein/venous pressure(WHVP)of the middle and left hepatic veins was similar at 29.71±12.48 and 29.1±10.91 mmHg,respectively,and the mean WHVP of the right hepatic vein was slightly lower at 28.01±8.95 mmHg.The mean portal vein pressure was 34.11±8.56 mmHg.The correlation coefficient and coefficient of determination of the right hepatic vein,middle hepatic vein,and left hepatic vein were 0.26 and 0.07(P=0.009);0.38 and 0.15(P<0.001);and 0.26 and 0.07(P=0.008),respectively.The average free hepatic venous pressure(FHVP)of the right hepatic vein was lowest at 11.67±5.34 mmHg,and the average FHVP of the middle and left hepatic veins was slightly higher at 12.19±4.88 and 11.67±5.34 mmHg,respectively.The average inferior vena cava pressure was 8.27±4.04 mmHg.The correlation coefficient and coefficient of determination of the right hepatic vein,middle hepatic vein,and left hepatic vein were 0.30 and 0.09(P=0.002);0.18 and 0.03(P=0.078);and 0.16 and 0.03(P=0.111),respectively.CONCLUSION Measurement of the middle hepatic vein HVPG could better represent PPG.Considering the high success rate of clinical measurement of the right hepatic vein,it can be the second choice.

Hepatic venous pressure gradient: Inaccurately estimates portal venous pressure gradient in alcoholic cirrhosis and portal hypertension

BACKGROUND Portal hypertension(PHT)in patients with alcoholic cirrhosis causes a range of clinical symptoms,including gastroesophageal varices and ascites.The hepatic venous pressure gradient(HVPG),which is easier to measure,has replaced the portal venous pressure gradient(PPG)as the gold standard for diagnosing PHT in clinical practice.Therefore,attention should be paid to the correlation between HVPG and PPG.METHODS Between January 2017 and June 2020,134 patients with alcoholic cirrhosis and PHT who met the inclusion criteria underwent various pressure measurements during transjugular intrahepatic portosystemic shunt procedures.Correlations were assessed using Pearson’s correlation coefficient to estimate the correlation coefficient(r)and determination coefficient(R^(2)).Bland-Altman plots were constructed to further analyze the agreement between the measurements.Disagreements were analyzed using paired t tests,and P values<0.05 were considered statistically significant.RESULTS In this study,the correlation coefficient(r)and determination coefficient(R2)between HVPG and PPG were 0.201 and 0.040,respectively(P=0.020).In the 108 patients with no collateral branch,the average wedged hepatic venous pressure was lower than the average portal venous pressure(30.65±8.17 vs.33.25±6.60 mmHg,P=0.002).Hepatic collaterals were identified in 26 cases with balloon occlusion hepatic venography(19.4%),while the average PPG was significantly higher than the average HVPG(25.94±7.42 mmHg vs 9.86±7.44 mmHg;P<0.001).The differences between HVPG and PPG<5 mmHg in the collateral vs no collateral branch groups were three cases(11.54%)and 44 cases(40.74%),respectively.CONCLUSION In most patients,HVPG cannot accurately represent PPG.The formation of hepatic collaterals is a vital reason for the strong underestimation of HVPG.

Accurate ultrasonography-based portal pressure assessment in patients with hepatocellular carcinoma

BACKGROUND Portal pressure is of great significance in the treatment of hepatocellular carcinoma(HCC),but direct measurement is complicated and costly;thus,noninvasive measurement methods are urgently needed.AIM To investigate whether ultrasonography(US)-based portal pressure assessment could replace invasive transjugular measurement.METHODS A cohort of 102 patients with HCC was selected(mean age:54±13 years,male/female:65/37).Pre-operative US parameters were assessed by two independent investigators,and multivariate logistic analysis and linear regression analysis were conducted to develop a predictive formula for the portal pressure gradient(PPG).The estimated PPG predictors were compared with the transjugular PPG measurements.Validation was conducted on another cohort of 20 non-surgical patients.RESULTS The mean PPG was 17.32±1.97 mmHg.Univariate analysis identified the association of the following four parameters with PPG:Spleen volume,portal vein diameter,portal vein velocity(PVV),and portal blood flow(PBF).Multiple linear regression analysis was performed,and the predictive formula using the PVV and PBF was as follows:PPG score=19.336-0.312×PVV(cm/s)+0.001×PBF(mL/min).The PPG score was confirmed to have good accuracy with an area under the curve(AUC)of 0.75(0.68-0.81)in training patients.The formula was also accurate in the validation patients with an AUC of 0.820(0.53-0.83).CONCLUSION The formula based on ultrasonographic Doppler flow parameters shows a significant correlation with invasive PPG and,if further confirmed by prospective validation,may replace the invasive transjugular assessment.

Endoscopic ultrasound-guided portal pressure gradient identifies patients with previously undiagnosed clinically significant portal hypertension

Aims:Portal hypertension(PH)is a complication of cirrhosis that leads to hepatic decompensation.Assessing the portal pressure gradient(PPG)provides valuable information for disease assessment,staging,and prognosis.In this study,we aimed to report the utilization of endoscopic ultrasound(EUS)-guided PPG(EUS-PPG)measurements in a real-world setting.Methods:This retrospective analysis included patients at a tertiary care center who underwent EUS-PPG between February 2021 and May 2022.The most common indication was to establish or exclude the diagnosis of cirrhosis,followed by an assessment of surgical risk in the setting of suspected cirrhosis.Extensive demographic and clinical data were collected,and statistical analysis was performed using the Student's t test.Results:Eighteen patients underwent EUS-PPG.Technical success was achieved in 17 of the 18 patients.No complications were observed.The mean scores of Child-Pugh,Model for End-Stage Liver Disease-Sodium,and Fibrosis-4 scores were 5.1±0.5,9.0±3.0,and 3.7±4.5,respectively.Of the 18 patients,two presented with esophageal varices and six with portal hypertensive gastropathy.The mean PPG was 5.8±4.5 mmHg,and five patients exhibited clinically significant PH(CSPH).Of the 18 patients,15 underwent concurrent EUS-liver biopsy,which was 100%successful and provided diagnostic histology for all patients.The PPG data led to changes in the clinical management of 17 patients.Conclusions:EUS-PPG is safe and technically feasible.The Child-Pugh score did not correlate well with the presence of CSPH;however,PPG measurements resulted in changes in the management of almost all patients.Larger studies correlating EUS-PPG with other assessments of liver diseases are required.

Transjugular intrahepatic portosystemic shunt:A promising therapy for recompensation in cirrhotic patients

This is a retrospective study focused on recompensation after transjugular intrahepatic portosystemic shunt(TIPS)procedure.The authors confirmed TIPS could be a treatment for recompensation of patients with cirrhosis according to Baveno VII.The paper identified age and post-TIPS portal pressure gradient as independent predictors of recompensation in patients with decompensated cirrhosis after TIPS.These results need to be validated in a larger prospective cohort.

Endoscopic ultrasound-guided vascular interventions: An expanding paradigm

Endoscopic ultrasound(EUS)has expanded its arena from a mere diagnostic modality to an essential therapeutic tool in managing gastrointestinal(GI)diseases.The proximity of the GI tract to the vascular structures in the mediastinum and the abdomen has facilitated the growth of EUS in the field of vascular interventions.EUS provides important clinical and anatomical information related to the vessels'size,appearance and location.Its excellent spatial resolution,use of colour doppler with or without contrast enhancement and ability to provide images“real-time”helps in precision while intervening vascular structures.Additionally,structures such as venous collaterals or varices can be dealt with optimally using EUS.EUS-guided vascular therapy with coil and glue combination has revolutionized the management of portal hypertension.It also helps to avoid radiation exposure in addition to being minimally invasive.These advantages have led EUS to become an upcoming modality to complement traditional interventional radiology in the field of vascular interventions.EUS-guided portal vein(PV)access and therapy is a new kid on the block.EUS-guided portal pressure gradient measurement,injecting chemotherapy in PV and intrahepatic portosystemic shunt has expanded the horizons of endo-hepatology.Lastly,EUS has also forayed into cardiac interventions allowing pericardial fluid aspiration and tumour biopsy with experimental data on access to valvular apparatus.Herein,we provide a comprehensive review of the expanding paradigm of EUS-guided vascular interventions in GI bleeding,portal vein access and its related therapeutic interventions,cardiac access,and therapy.A synopsis of all the technical details involving each procedure and the available data has been tabulated,and the future trends in this area have been highlighted.

Update on endoscopic ultrasound-guided liver biopsy

Endoscopic ultrasound guided liver biopsy(EUS-LB)has emerged as a minimally-invasive alternative to the traditional(percutaneous or transjugular)liver biopsy techniques for the diagnosis of liver parenchymal diseases.Potentially,EUS-LB combines the advantages of percutaneous and transjugular liver biopsy in addressing focused sampling in addition to measuring portal pressure.Additionally,EUS-LB facilitates access to both the lobes of the liver which is not considered with the traditional percutaneous liver biopsy.Multiple studies have compared EUS-LB with conventional liver biopsy and reported comparable diagnostic yield,increased acquisition of complete portal tracts,and longer specimen length as compared to the traditional approaches.EUS-LB is associated with lesser post-procedural pain and shorter recovery time,while providing lower risk of complications when compared to traditional liver biopsy.Innovations in needle types,needle sizes and suction techniques have aimed at further optimizing the EUS-LB technique.This review article updates current literature with focus on the variations in the technique and equipment used for EUS-LB,and compares EUS-LB with traditional methods of liver biopsy.

Innovations in endoscopic ultrasound for portal hypertension and its role in managing complications in clinical practice:Lessons learned from a tertiary referral public hospital

Portal hypertension(PH)poses significant challenges.This paper presents an innovative study on the utilization of endoscopic ultrasound(EUS)for both the diagnosis and management of PH.Conducted at Dr.Cipto Mangunkusumo National General Hospital in Jakarta,this retrospective case series included patients diagnosed with PH through clinical examination,imaging evaluation,and esophagogastroduodenoscopy.Exclusion criteria comprised a history of reduced blood consumption within the last 5 days,hepatocellular carcinoma,massive ascites,or elevated international normalized ratio(>1.4).EUS-guided portal pressure gradient(PPG)measurements were performed using an innovative standard manometer.The study involved 15 patients,with 14 having liver cirrhosis and 1 diagnosed with Budd–Chiari syndrome.Among them,nine patients experienced bleeding due to gastroesophageal varices.Small and large esophageal varices were identified in four and eight patients,respectively.Gastroesophageal varices type 1 were observed in two patients,and type 2 in four patients.Isolated gastric fundal varices type 1 were present in one patient.Based on EUS-PPG measurements,14 patients exhibited clinically significant portal hypertension.Seven patients underwent endoscopic band ligation and three underwent EUS-guided cyanoacrylate injection during the same session as the EUS-PPG measurement procedure.Notably,no adverse events,such as abdominal pain,perforation,or bleeding were observed during or after the procedure.EUS emerges as a promising and accurate tool for both diagnosis and management.