Prognostic performance of endoscopic ultrasound-guided portal pressure gradient: preliminary results from the EVADIPP study

Background and Aims: Clinically significant portal hypertension (CSPH) is the main driver of hepatic decompensation, and its early identification allows timely initiation of preventive therapies. Hepatic Venous Pressure Gradient (HVPG) is the current gold standard for assessing portal hypertension (PH), but it may underestimate PH in conditions with a presinusoidal component. Endoscopic ultrasound-guided portal pressure gradient (EUS-PPG) enables direct measurement of portal pressure and may overcome these limitations. We evaluated the prognostic performance of EUS-PPG compared with HVPG for predicting hepatic decompensation in patients with suspected CSPH. Approach and Results: This preliminary exploratory analysis of the ongoing prospective EVADIPP study included 90 patients who underwent paired HVPG and EUS-PPG measurements and were followed for decompensation. Mean EUS-PPG and HVPG values were 13.8 ± 5.8 mmHg and 8.9 ± 4.8 mmHg, respectively, with poor overall agreement (ICC 0.08, 95% CI −0.08 to 0.24). Agreement remained poor in porto-sinusoidal vascular disorder (PSVD), slight in metabolic dysfunction-associated steatotic liver disease, and substantial in alcohol- and viral-related liver disease. During follow-up, 28 patients (31%) developed decompensation; no events occurred among patients with EUS-PPG<10 mmHg, whereas 60.7% had HVPG <10 mmHg. In multivariable analysis, EUS-PPG (HR 1.19, 95% CI 1.10–1.30; p<0.001) and albumin were independently associated with decompensation. EUS-PPG demonstrated better discrimination than HVPG (C-index 0.78 vs 0.56), and time-dependent ROC analysis identified an optimal threshold of 12 mmHg. Conclusions: EUS-PPG is independently associated with hepatic decompensation and showed better prognostic discrimination than HVPG in this exploratory cohort.