Transjugular diagnostic procedures in hepatology: Indications, techniques and interpretation

Abstract

Measurement of the hepatic venous pressure gradient (HVPG) and transjugular liver biopsy have emerged as important tools in clinical hepatology. Measurement of HVPG is considered the gold standard for detecting clinically significant portal hypertension, with an HVPG of ≥10 mmHg being the key prognostic threshold in patients with compensated advanced chronic liver disease (cACLD; compensated cirrhosis). A transjugular liver biopsy can be obtained within the same procedure and may be preferred over percutaneous liver biopsy in patients with coagulopathy, ascites and/or significant obesity. Endoscopic ultrasound-guided procedures are currently under investigation and require standardisation. This article summarises critical technical aspects of HVPG measurements and transjugular liver biopsy and provides a detailed overview of their current role in the context of emerging non-invasive tests and endoscopic approaches.

Keywords: Cirrhosis; HVPG; PSVD; hepatic venous pressure gradient; minimally invasive; portal hypertension; porto-sinusoidal vascular disorder; transjugular liver biopsy.

Graphical abstract

Fig. 1

Concept of HVPG measurement. Sinusoidal portal hypertension, as typically seen in patients with viral and ALD-associated cirrhosis, is characterised by interruption of inter-sinusoidal channels. If a balloon catheter is wedged in the hepatic vein, a static pressure column is transmitted into the portal vein. As the inter-sinusoidal channels are closed, the pressure cannot be buffered. Therefore, WHVP equilibrates the PP and HVPG adequately depicts the PSG (A). In patients with non-cirrhotic portal hypertension or with increased pre-sinusoidal resistance, the inter-sinusoidal channels are open and can buffer the static pressure column. In this situation the WHVP underestimates the PP (B). Adapted from. Created with biorender.com. FHVP, free hepatic vein pressure, IVC, inferior vena cava; PP, portal pressure; PSG, portosystemic gradient; WHVP, wedged hepatic vein pressure.

Fig. 2

Venography during HVPG measurement. (A) Confirmation of the wedge (occlusion) position in the right hepatic vein with the balloon inflated by injecting contrast medium. (B) Veno-venous communication vessels. HVPG, hepatic venous pressure gradient.

Fig. 3

Pressure recording of FHVP, WHVP, FHVP ret., IVC pressure, and RAP. Pressure recording of the FHVP (FHVP1-3), WHVP (WHVP1-3), the optional retracted FHVP (max. 2-3 cm from the junction with the IVC; FHVP ret.), the IVCP and RAP. The “retracted” FHVP is better for calculating the hepatic venous pressure gradient, if the WHVP is measured far peripherally. FHVP, free hepatic vein pressure; FHVP ret., retracted FHVP; IVC, inferior vena cava; IVCP, IVC pressure; RAP, right arterial pressure; WHVP, wedged hepatic vein pressure.

Fig. 4

Positioning of the catheter in the right hepatic vein followed by pushed core liver biopsy. (A,B) Confirmation of the position of the introduction catheter in the right hepatic vein by injecting contrast medium (A), followed by the pushed core liver biopsy (B). (C) A schematic description of TJLB is provided.