P0650 - A Case of Simultaneous EUS-Guided Portal Pressure Gradient Measurement and IR-guided HVPG Measurement Post-TIPS

Award: Presidential Poster Award

Award: Presidential Poster Award

Alyssa Y. Choi, MD¹, Anastasia Chahine, MD¹, Jennifer Kolb, MD, MS², Sagar Shah, MD³, Kenneth Chang, MD⁴, James Katrivesis, MD⁵, Jason Samarasena, MD^6
1H. H. Chao Comprehensive Digestive Disease Center, University of California Irvine, Orange, CA; ²University of California Irvine, Orange, CA; ³University of California Los Angeles, Los Angeles, CA; ⁴Digestive Health Institute, UC Irvine, Orange, CA; ⁵University of California-Irvine, Orange, CA; ⁶University of California - Irvine, Orange, CA

Introduction: Hepatic venous pressure gradient (HVPG) and endoscopic ultrasound guided portal pressure gradient (EUS-PPG) measurements have been individually validated to measure the portosystemic pressure gradient. This case report compares EUS-PPG with IR-HVPG in a patient post transjugular intrahepatic portosystemic shunt (TIPS).

Case Description/Methods: A 75 year old male with NAFLD cirrhosis (MELD 14, MELD-Na 18, Child Pugh Class B) with recurrent variceal bleeding underwent TIPS four months ago. EUS-PPG was performed at the time of IR-guided HVPG measurement for TIPS assessment.



First, IR performed the HVPG measurement. Using ultrasound guidance, a 21-gauge needle was used to access a patent right internal jugular vein. A wire was advanced to the IVC and a 6 French sheath was placed. The free IVC pressure near the right atrium was measured to be 18 mmHg. A pigtail catheter was advanced over a guidewire to the main portal vein. The main portal pressure was measured at 30 mmHg. A portal venogram demonstrated brisk flow through the TIPS stent without evidence of stenosis or variceal filling (Figure 1a).



Next, GI performed the EUS-PPG measurement. A compact manometer was set to zero at the mid-axillary line before echoendoscope insertion. A linear echoendoscope was used to identify the IVC at the proximal edge of the TIPS seen on EUS (Figure 1b). The IVC was targeted using a 25-gauge fine needle aspiration needle via a trans-gastric approach. The IVC mean pressure measurement was 18 mmHg. When the PV was targeted, there was evidence of a non-occlusive left portal vein thrombus. The pressure readings were targeted just above the thrombus (Figure 1c, d). The mean PV pressure was 30.6 mmHg (over three measurements).



No TIPS modification was required. The needle was withdrawn from the liver after no doppler signal was present within the needle track. At the conclusion of both procedures the sheath in the right IJ was removed and hemostasis achieved with manual compression. The patient tolerated the procedure well without periprocedural complications.

Discussion: The EUS-PPG was 12.6 mmHg and the IR-HVPG was 12 mmHg. This first case of post-TIPS evaluation using same session EUS-PPG and IR- HVPG measurements demonstrated excellent correlation in portosystemic pressure gradients further validating the use of EUS-guided Portal Pressure Gradient Measurement in clinical practice.


Figure: Figure 1


Disclosures:
Alyssa Choi indicated no relevant financial relationships.
Anastasia Chahine indicated no relevant financial relationships.
Jennifer Kolb indicated no relevant financial relationships.
Sagar Shah indicated no relevant financial relationships.
Kenneth Chang: Cook Medical – Consultant, Patent Holder. Olympus – Consultant.
James Katrivesis indicated no relevant financial relationships.
Jason Samarasena: Cook Medical – Grant/Research Support. Olympus – Consultant.


Alyssa Y. Choi, MD¹, Anastasia Chahine, MD¹, Jennifer Kolb, MD, MS², Sagar Shah, MD³, Kenneth Chang, MD⁴, James Katrivesis, MD⁵, Jason Samarasena, MD⁶. P0650 - A Case of Simultaneous EUS-Guided Portal Pressure Gradient Measurement and IR-guided HVPG Measurement Post-TIPS, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.