Scientific Session 09 — SS09: Vascular/Interventional - Hepatic Interventions/Interventional OncologyTuesday, May 7, 2019
3048. Wedged Hepatic Venous Pressure as a Surrogate for Direct Portal Pressure: Is it Always Accurate?
Peng R1*, Krausz S2, Jagust M1, Golowa Y1, Cynamon J1 1. Montefiore Hospital, Bronx, NY; 2. Einstein Hospital, New York, NY
Address correspondence to R. Peng (firstname.lastname@example.org)
Objective: Hepatic vein catheterization is the preferred technique to evaluate for the presence and severity of portal hypertension. Hepatic venous pressure gradient is used to predict liver fibrosis, outcome of an acute variceal bleed, efficacy of beta blocker prophylaxis, and postoperative outcome in hepatocellular carcinoma to direct patient treatment and to determine an accurate prognosis. Wedged hepatic venous pressure (WHVP) is measured by occluding the hepatic vein either with a balloon occlusion catheter or a wedged-end-hole catheter. In cirrhosis, WHVP can give an estimation of direct portal pressures (DPPs). In the presence of intrahepatic hepatic venous collaterals, there may be pressure equilibration through the collaterals, which can result in discordant measurements. The aim of this study is to investigate the accuracy of WHVP as a surrogate for DPP.
Materials and Methods: This is a retrospective study at a single tertiary care institution of patients who underwent transjugular intrahepatic portosystemic shunt with the aid of balloon occlusion CO2 venography between November 2017 and August 2018. Hepatic venous pressures, including free and wedged, and DPP were recorded. The cases were reviewed to evaluate for the presence of intrahepatic hepatic venous collaterals and the opacification of the peripheral and/or central portion portal veins on CO2 venography. The WHVP and DPP were compared and assessed for discrepancies greater than 5 mmHg.
Results: Our review included 20 cases with a mean WHVP of 23.9 +/- 6.0 mmHg, a mean DPP of 28.9 +/- 5.8 mmHg, and a mean pressure discrepancy of 5.0 +/- 8.0 mmHg. Intrahepatic hepatic venous collaterals were visible in 60% of cases (12/20) with a mean pressure discrepancy of 9.2 +/- 7.4 mmHg. The presence of collaterals resulted in an accuracy of only 33%, because a discrepancy of greater than 5mmHg was present in 67% of cases (8/12); this number included cases with collaterals and portal venous system opacification (6) and cases with collaterals and no portal venous system opacification (6). In cases without visualization of intrahepatic hepatic venous collaterals (8/20), there was a mean discrepancy of -1.3 +/- 3.6 mmHg. In the cases without collaterals, the WHVP was 100% concordant with the DPP, because there were no cases with a discrepancy greater than 5 mmHg.
Conclusion: When balloon occlusion CO2 hepatic venography demonstrates the absence of intrahepatic hepatic venous collaterals, there is a suggestion that the WHVP is highly concordant with the DPP. In the presence of intrahepatic hepatic collaterals, although portal hypertension was demonstrated, there may be discrepancies between the WHVP and DPP. This study is limited to CO2 injection through a balloon occlusion catheter. Further study is needed to investigate these findings in cases with wedged-end-hole catheter or iodinated contrast agent.