Reiberger Thomas, Schwabl Philipp, Trauner Michael, Peck-Radosavljevic Markus, Mandorfer Mattias
Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna; Vienna Hepatic Hemodynamic Lab, Medical University of Vienna;
Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna; Vienna Hepatic Hemodynamic Lab, Medical University of Vienna.
J Vis Exp. 2020 Jun 18(160). doi: 10.3791/58819.
Here we provide a detailed protocol describing the clinical procedure of hepatic venous pressure gradient (HVPG) measurement in patients with advanced chronic liver disease followed by an instruction for transjugular biopsy. Under local anesthesia and ultrasound guidance, a catheter introducer sheath is placed in the right internal jugular vein. Using fluoroscopic guidance, a balloon catheter is advanced into the inferior vena cava (IVC) and inserted into a large hepatic vein. Correct and sufficient wedge position of the catheter is ensured by injecting contrast media while the balloon is blocking the outflow of the cannulated hepatic vein. After calibrating the external pressure transducer, continuous pressure recordings are obtained with triplicate recordings of the wedged hepatic venous pressure (WHVP) and free hepatic venous pressure (FHVP). The difference between FHVP and WHVP is referred to as HVPG, with values ≥10 mm Hg indicating clinically significant portal hypertension (CSPH). Before removing the catheter, pressure readings obtained in the IVC at the same level, as well as the right atrial pressure are recorded. Finally, a transjugular liver biopsy can be obtained via the same vascular route. Different systems are available; however, core biopsy needles are preferred over aspiration needles, especially for cirrhotic livers. Again, under fluoroscopic guidance a biopsy needle introducer sheath is advanced into an hepatic vein. Next, the transjugular biopsy needle is gently advanced through the introducer sheath: (i) in case of aspiration biopsy, the needle is advanced into the liver parenchyma under aspiration and then removed quickly, or (ii) in case of a core biopsy, the cutting-mechanism is triggered inside the parenchyma. Several separate passages can be safely performed to obtain sufficient liver specimens via transjugular biopsy. In experienced hands, the combination of these procedures takes about 30-45 min.
在此，我们提供一份详细方案，描述晚期慢性肝病患者肝静脉压力梯度（HVPG）测量的临床操作步骤，随后是经颈静脉活检的说明。在局部麻醉和超声引导下，将导管导入鞘置于右颈内静脉。在荧光透视引导下，将球囊导管推进至下腔静脉（IVC）并插入一条粗大的肝静脉。通过在球囊阻断插管肝静脉流出时注入造影剂，确保导管处于正确且充分的楔形位置。在校准外部压力传感器后，连续记录压力，对肝静脉楔压（WHVP）和游离肝静脉压（FHVP）进行三次重复记录。FHVP与WHVP的差值即为HVPG，值≥10 mmHg表明存在临床显著门静脉高压（CSPH）。在移除导管前，记录在同一水平IVC测得的压力读数以及右心房压力。最后，可通过相同的血管路径进行经颈静脉肝活检。有不同的系统可供使用；然而，对于肝硬化肝脏，活检针优于抽吸针。同样，在荧光透视引导下，将活检针导入鞘推进至一条肝静脉。接下来，将经颈静脉活检针轻轻穿过导入鞘：（i）对于抽吸活检，在抽吸状态下将针推进至肝实质，然后迅速拔出，或者（ii）对于活检针活检，在肝实质内触发切割机制。通过经颈静脉活检可以安全地进行几次单独的穿刺，以获取足够的肝脏标本。在经验丰富的操作者手中，这些操作组合大约需要30 - 45分钟。
