EUS-guided intrahepatic portosystemic shunt with direct portal pressure measurements: a novel alternative to transjugular intrahepatic portosystemic shunting

Abstract Background and Aims Transjugular intrahepatic portosystemic shunting (TIPS) involves the creation of a low-resistance channel between the portal vein (PV) and the hepatic vein (HV), and routinely performed under angiography. The aims were to evaluate 1) safety and technical feasibility; 2) procedural duration; and 3) subjective workload assessment of endoscopic ultrasound (EUS)-guided intrahepatic portosystemic shunt (EIPS). Methods Subjects : 5 Yorkshire pigs. Procedure: The HV, or inferior vena cava (IVC), was identified using a linear-array echoendoscope and accessed with a 19-G FNA needle preloaded with a digital pressure wire. Mean pressure was recorded. The needle was advanced into the PV, where pressure measurements were again taken, and ultimately exchanged over a guidewire. A lumen-apposing metal stent (LAMS) was deployed under EUS and fluoroscopic guidance, with distal and proximal ends positioned inside the PV and HV (IVC), respectively. Dilation was performed, and pressure measurements repeated. NASA task load index (TLI) was scored. Animals survived 2 weeks before necropsy. Results EIPS was successful in 5 out of 5 pigs. Mean time required for EUS identification, needle access, pressure measurement, and stent placement was 43 (31-55) minutes. NASA TLI scores revealed moderate workload. Mean baseline pressure measurements were PV 7.0 (5-9) and HV/IVC 5.0 (3-7) mm Hg and PV 6.3 (5-7) and HV/IVC 6.0 (4-7) mm Hg after. All animals survived 2 weeks. No bleeding was seen on necropsy. Conclusions This study demonstrates technical feasibility of EIPS using LAMS, with direct portal pressure measurement, in a survival model. Additionally, the procedure was performed quickly with moderate technical demand.