Endoscopic ultrasound-guided vascular interventions: An expanding paradigm

Table 6 Technique for assessing endoscopic ultrasound-guided portal pressure gradient

Procedural steps for measuring EUS-PPG
The measurement of PPG via EUS requires 4 components: 25-G FNA needle, non-compressible tubing, a compact digital manometer, and heparinized saline. The tubing is connected by a luer lock to the distal port and heparinized saline is connected the proximal port of the manometer
With the patient supine, the manometer is placed at the patient’s midaxillary line
The HV measurement is conducted first, in which middle HV is targeted most often (larger calibre and better alignment with the needle trajectory). Then PV measurement is taken (umbilical portion of left PV is the target)
Doppler flow is used to confirm the typical multiphasic waveform of hepatic venous flow and typical venous hum of the portal venous flow
Trans-gastric trans-hepatic route is taken for HV and PV puncture
Needle is flushed with heparinized saline (1 mL). The steadiest reading at equilibrium is recorded. Three measurements are taken and their mean is calculated (both HV and PV pressures)
The FNA needle is slowly withdrawn from the vein into the liver parenchyma and then back into the needle sheath with Doppler flow on to ensure there is no flow within the needle tract

EUS: Endoscopic ultrasound; PPG: Portal pressure gradient; G: Gauge; FNA: Fine needle aspiration; PV: Portal vein; HV: Hepatic vein.