Endoscopic Ultrasound–Guided Dual Ultrasound Hepatic Cyst Aspiration and Sclerotherapy to Ameliorate Portal Hypertension

Abstract

The interventional radiology-guided hepatic venous pressure gradient (IR-HVPG) can diagnose portal hypertension (P-HTN), predict sequelae, and guide its management. IR-HVPG measurements may be inaccurate due to presinusoidal P-HTN or inability to access hepatic vein (HV). This limitation is overcome by endoscopic ultrasound (EUS) direct portal vein and portosystemic pressure gradient (EUS PPG) measurement. We highlight a 51-year-old man with autosomal dominant polycystic kidney and liver disease who underwent bilateral nephrectomy with kidney transplantation complicated by inferior vena cava transection with expanded polytetrafluoroethylene interposition graft repair (a). He developed deteriorating renal function, ascites, and bowel wall thickening. Accurate IR-HVPG recordings were unobtainable because HV was nonaccessible due to distortion by hepatic cysts. He subsequently underwent EUS with the measurements of splenic vein pressure (23 mm Hg), and given HV cyst compression, direct inferior vena cava pressure (8 mm Hg) yielding a PPG of 15 mm Hg (b). EUS fluid aspiration (255 mL) from 4 cysts permitted HV visualization and Pulse Doppler flow detection that was undetectable preaspiration. Immediate retesting revealed an EUS PPG of 11 mm Hg, representing a significant decrease of 27%, implicating HV cyst compression as an etiologic factor in the patient's P-HTN. We subsequently performed simultaneous transabdominal ultrasound and EUS to target peripheral and central cysts, aspirating 490 mL of fluid, followed by an injection of 12 mL of 3% sotradecol as a sclerosant (c). Contrast injection with fluoroscopy confirmed absence of communication with blood vessels and bile ducts. Thereafter, the patient experienced a marked improvement in all clinical manifestations of his P-HTN and recovered his renal function. This report highlights the potential for EUS to: (i) establish the presence and degree of P-HTN when IR-HVPG measurements are unobtainable, (ii) perform measurements prehepatic and posthepatic cyst aspiration to implicate hepatic cyst