This ASG video tip is brought to you by an educational grant from Braintree, a part of Cibela Pharmaceuticals, makers of SUTAB. So this is the equipment setup of the original device that we use and the currently FDA approved device is very similar. So 25 gauge FNA needle. This is the manometer and then heparanized saline. So we connect the manometer to the non-compressible tubing. Attach the heparanized saline. And once the stylet is out, you attach the non-compressible tubing to the inlet of the FNA needle. And then we place the manometer at the level of the mid axillary line. This is to represent keeping it level at the phlebostatic axis of the heart. So when we do EUS guided portal pressure gradient measurement, we're actually doing a transgastric transparenchymal puncture of the hepatic vein. And then again, a transgastric transparenchymal puncture of the portal vein. And I think this is part of the reason why this is so safe. You're going through essentially liver tissue before you go into the vessel. So here's a video demonstrating. So here we can see on EUS, we've gone through the liver parenchyma, we've punctured the hepatic vein, and then we flush with a little bit of heparanized saline and you often see, and you'd like to see some bubbles from the heparanized saline in the vein. And then what you'll see is the numbers on the manometer will go up high and then they'll come down and then they'll stabilize. And this is very similar to the way it's done with interventional radiology in terms of looking at these numbers. We usually take three measurements in the hepatic vein and then take an average of the hepatic vein measurements. And then we'll come out of the hepatic vein and move to position for a portal vein puncture. And here you can see the needle in the portal vein. Again, we're going to do a flush of a small amount of heparanized saline. The numbers will again go up and then come down and level out. And in this case, the portal venous pressure was 26, hepatic venous pressure was 12. So the portal pressure gradient was 14, consistent with clinically significant portal hypertension.

EUS-guided portal pressure gradient measurement

equipment setup

procedure

portal pressure gradient

portal hypertension