Measurement of the Hepatic Venous Pressure Gradient and Transjugular Liver Biopsy

Patients with cirrhosis are at risk for developing complications mostly related to portal hypertension (PHT), such as ascites or bleeding from gastric or esophageal varices^1,2,3. The risk of hepatic decompensation is related to the degree of PHT². Measurement of the hepatic venous pressure gradient (HVPG) is the gold standard to estimate portal venous pressure in patient with cirrhosis, i.e. assessing the severity of sinusoidal portal hypertension⁴. An HVPG of ≥6 mm Hg to 9 mm Hg indicates elevated portal pressure ('subclinical portal hypertension'), while an HVPG ≥10 mm Hg defines CSPH. This protocol provides a detailed description of the equipment and the procedure and also highlights potential pitfalls and offers advice for troubleshooting.

Clinically, measurement of HVPG is indicated (i) to establish the diagnosis of sinusoidal portal hypertension, (ii) to identify patients at risk for hepatic decompensation by diagnosing CSPH (HVPG ≥10 mm Hg), (iii) to guide pharmacological therapy in primary or secondary prophylaxis of variceal bleeding, and (iv) to assess the risk of hepatic failure after partial hepatectomy^2,4. HVPG is used as an established surrogate marker for improvement and/or worsening of liver fibrosis/function, since a decrease in HVPG translates into a clinically meaningful benefit⁵, whereas higher HVPG values are associated with an increased variceal bleeding risk⁶. Based on observations on changes in HVPG in patients under non-selective beta-blocker (NSBB) or etiological therapies, a decrease in HVPG of 10% is considered to be clinically relevant^7,8.

To date, there are no alternative, non-invasive parameters reflecting the degree of portal pressure with similar accuracy as HVPG. Even if HVPG is actually an ‘indirect’ way to measure portal pressure, it strongly correlates and thus accurately reflects ‘directly’ measured portal pressure in patients with cirrhosis⁹. Importantly, HVPG measurements should be performed using a balloon catheter to maximize the assessed amount of liver parenchyma^10,11,12. Although HVPG measurements are invasive, resource-intensive, and require interventional skills and expertise in interpreting the reliability and plausibility of pressure readings, this method is the current gold standard for diagnosing and monitoring portal hypertension in patients with cirrhosis^13,14,15.

Simple laboratory values, such as platelet count, may help to estimate the likelihood for CSPH. However, platelet count, or non-invasive scores that include platelet count, have limited predictive value¹⁶. Imaging modalities showing splenomegaly¹⁷ or portosystemic collaterals¹⁸ in patients with cirrhosis suggest the presence of CSPH, but are not helpful for quantifying the actual degree of portal hypertension. Novel non-invasive imaging tools, such as elastography of the liver¹⁹ and/or of the spleen²⁰ are useful for ruling-in or ruling-out the presence of CSPH. Still, none of the available methods is able to directly measure dynamic changes in portal pressure²¹.

The prognostic value of HVPG has been underlined by several landmark studies, showing that a HVPG ≥10 mm Hg (i.e. CSPH) is predictive for the formation of varices⁸ (and for the development of complications related to portal hypertension²², while a (pharmacologically-induced) decrease of HVPG modulates the respective risk of variceal growth²³ and decompensation⁷. HVPG-response is the only established surrogate for the effectiveness of NSBBs in preventing (recurrent) variceal bleeding. If HVPG decreases to a value of ≤12 mm Hg or is reduced by ≥10-20% during NSBB treatment, patients are protected from variceal bleeding and survival is increased^24,25. Similarly, HVPG-response also decreases the incidence of ascites and related complications in patients with compensated cirrhosis^5,26. Several studies have provided evidence supporting the use of HVPG-guided therapy^{27,28,29,30,31,32}. Thus, in centers with sufficient experience, HVPG-response may guide treatment decisions, facilitating personalized medicine for patients with portal hypertension.

Moreover, measuring of HVPG might serve as a surrogate endpoint for proof-of-concept studies assessing the effectiveness of novel treatments for cirrhosis and/or portal hypertension being translated from bench to bedside, such as sorafenib^33,34, simvastatin^35,36, taurine³⁷, or emricasan³⁸. Ultimately, measurements of HVPG can also provide important prognostic information about the risk for development of HCC³⁹ and for liver failure post hepatic resection⁴⁰.

The infrastructure to measure HVPG should be readily available at secondary and tertiary care centers. Since the technique of HVPG measurement requires specialized training and equipment, it seems rational for academic and transplant centers to establish a hepatic hemodynamic laboratory, facilitating state-of-the-art diagnosis and management of portal hypertension. Large volume centers perform several hundred HVPG measurements per year. Based on our experience, sufficient expertise to perform accurate HVPG measurements is usually obtained after 50-100 supervised HVPG measurements.

The protocol described here complies with the guidelines of the human research ethics committee of the Medical University of Vienna.

1. Preparations

1. Use a specialized room dedicated/approved for procedures using x-ray equipped with a digital x-ray fluoroscopy system (Figure 1A), a monitor system (Figure 1B), a pressure recorder and transducer (Figure 1C) that are connected to a printer or recording software, and an ultrasound device (Figure 1D). Also, ensure there is sufficient space for a sterile working area (Figure 1E) next to the patient bench.
2. Evaluate patients with suspected advanced chronic liver disease (ACLD) for CSPH by measurement of HVPG. In particular, patients with one of the following features might undergo HVPG measurement: thrombocytopenia <150 G/L, portosystemic collaterals on cross-sectional imaging, gastroesophageal varices prior to initiation of non-selective betablocker therapy, ascites, and hepatic tumors that are scheduled for resection.
3. Use the following contraindications for the procedure: (i), absence of vascular access due to jugular or caval vein thrombosis, (ii) clinically evident bleeding disorders (e.g. disseminated intravascular coagulation), (iii) contralateral pneumothorax, and (iv) significant cardiac arrhythmias.
4. Ensure that the patient is fastened and gave written informed consent after being informed about the purpose and potential risks of the procedure.
5. Explain that the procedure must be performed without general anesthesia. However, low doses of midazolam (up to 0.02 mg/kg bodyweight) might be offered to anxious patients.
6. Monitor the patient’s vital signs by non-invasive arterial blood pressure measurement, pulse oximetry, and electrocardiography using a standard monitor system.
7. Flush the pressure transducer set using sterile saline solution in a pressure bag.
8. Calibrate the pressure transducer (if not precalibrated, calibrate against an external pressure reference before starting measurements, e.g. by using a water column where 13.6 cm H₂O equals 10 mm Hg).
9. Place the transducer at the level of the right atrium by aiming at the patient’s midaxillary line.
10. Prepare the pressure recorder/recording software to be ready for recording pressure tracings.
11. Ensure that all necessary sterile equipment is ready (see Table of Materials).
12. Ask the patient to take a supine position on the patient bench.
13. Have the operator wash and disinfect her/his hands and forearms.
14. Put on surgical cap and face mask, sterile gloves and a sterile coat.
15. Use a sterile table cover and prepare a sterile working area for the equipment needed for the central venous access (Figure 2A).

2. Central venous access under sterile conditions

1. Instruct the patient to turn his/her head slightly to the left side, then disinfect the area of the right anterior and lateral neck with a disinfectant solution.
2. Place sterile towels that cover the skin around the carotid triangle.
3. Use a ultrasound probe (covered by a sterile US probe cover sheath) to identify the right internal jugular vein and the appropriate puncture site.
4. Infiltrate the area of subsequent vascular access with a 21 G needle and apply a local anaesthetic (lidocaine 2%, 5 mL). Then, wait 1–2 min for its full effect.
5. Prepare all materials needed for central venous access (see Table of Materials).
6. Using the equipment of the 7.5 F catheter introducer sheath set, place the needle in the right internal jugular vein using ultrasound guidance and advance the guidewire through the needle using the Seldinger technique (Figure 3A).
   NOTE: If a transjugular biopsy should be performed after HVPG measurement, a larger diameter 10 F liver biopsy introducer sheath set (with extra 18 G needle and guide wire) has to be used.
7. Make a 2-3 mm incision along the guidewire using a blade 11 scalpel to ease introduction of the vascular access sheath loaded with the dilatator.
8. Insert the vascular access percutaneous sheath loaded with the dilatator into the internal jugular vein over the guidewire.
9. Remove the guidewire and the dilatator of the vascular access sheath.
10. Make sure that the vascular access sheath remains in a stable intravascular position and orient the injection port of the vascular access sheath towards the lateral side (Figure 3B).
    NOTE: Suturing or taping is not needed.

3. Placement of the balloon catheter in a hepatic vein

1. Prepare all materials needed for placement of the balloon catheter into a hepatic vein (Figure 2B).
2. Flush the balloon catheter with contrast media (dye) and check the integrity of the balloon by repetitive insufflation/deflation with the catheter tip immersed in saline solution. No air bubbles should occur.
   NOTE: Depending on the visibility of the catheter itself on x-ray, you may also use just sterile saline or diluted dye to flush the vascular lumen of the catheter.
3. Moisten the balloon catheter on the outside with sterile saline solution before inserting it into the vascular access sheath.
4. Advance the balloon catheter under fluoroscopic guidance into the inferior cava vein (IVC). Aligning the tip of the balloon catheter towards the back of the patient and slight rotations of the catheter usually allows to advance from the right atrium to the IVC. Instructing the patient to inhale deeply might help in some cases (Figure 3B).
5. Advance the balloon catheter from the IVC into the hepatic vein. Try to get access to the hepatic veins by repeatedly moving with the tip of the balloon catheter facing to the right towards the suspected area of the junction of the hepatic veins and the IVC (Figure 3C).
6. Ensure that the catheter is advanced into a stable position that allows the repeated measurement of the free hepatic venous pressure (FHVP) at a 2-4 cm distance from its opening into the IVC and adequate space for the inflated balloon in the lumen of the hepatic vein in order to record the wedged hepatic venous pressure (WHVP).
7. Check for an adequate occlusion of the vein (wedge position) by inflating the balloon (about 2 mL of air into the balloon lumen) and contrast agent injection (about 5 mL into the vascular lumen) until the hepatic vein distal to the inflated balloon is visualized (Figure 3D).
8. Observe the stasis of the contrast media and exclude washout of the contrast media due to insufficient occlusion of the venous lumen by the balloon or due to the presence of vein-vein communications. If significant contrast media washout is observed, try to reposition the balloon catheter.
9. Deflate the balloon and flush the lumen of the catheter with saline.

4. Hemodynamic readings for assessing the HVPG

1. Connect the vascular lumen of the balloon catheter to the pressure transducer using an infusion line.
2. Start recording the FHVP with the tip of the balloon 2-4 cm from the opening of the hepatic vein to the IVC. The waveform of the curve must be stable without variations over time.
   NOTE: Stable values are usually obtained after 15 s.
3. Inflate the balloon and continue recording the WHVP until the measurement becomes a stable horizontal line with no variations over time.
   NOTE: Stable tracings of the wedged pressure are usually obtained after >40 s.
4. Repeat the measurement of FHVG (>15 s) and WHVP (>40 s) at least three times to obtain triplicate high-quality readings (Figure 3E).
   NOTE: If significant discrepancies of ≥2 mm Hg are observed between the single FHVP/WHVP readings, additional measurements should be obtained. Note the reasons for potential artefacts, such as coughing, moving, or talking at the respective timepoints of hemodynamic recording.
5. Record pressure in the IVC at the level of the ostium of the hepatic vein as well as the right atrial pressure (RAP).
6. Stop recordings.
7. Remove the balloon catheter.
8. Calculate HVPG (FHVP subtracted from WHVP) as the mean of 3 measurements.
   NOTE: If significant differences ≥2 mm Hg are noted between the sequentially obtained HVPG readings, additional measurements should be obtained.
9. Proceed to transjugular biopsy (step 5.1) or remove the catheter introducer sheath from the internal jugular vein.
   NOTE: Inserting a stiff guidewire may help to reach the same intrahepatic position for subsequent transjugular liver biopsy.
10. Apply pressure on top of the vascular insertion site of the internal jugular vein for at least 5 min using a sterile gauze.

5. Preparation for transjugular liver biopsy

NOTE: Two different biopsy methodologies may be used to obtain a transjugular liver biopsy: aspiration (step 6) or core biopsy (step 7). First decide which system to use and then select the appropriate biopsy needle introducer sheath before proceeding with steps 5.1 to 5.3). Alternatively, the needle of the core TJBLX set can also be inserted into the aspiration set (NOTE: use appropriate diameters), which results in a more flexible core biopsy system that may be easier to introduce into a hepatic vein (NOTE: this approach is not described in detail here).

1. Prepare the respective transjugular liver biopsy (TJLBX) set (aspiration TJLBX: Figure 4A-B; core TJLBX: Figure 4C; see Table of Materials).
2. Flush the biopsy needle introducer sheath with sterile saline or, in case of transjugular aspiration liver biopsy, with contrast agent for better visualization.
3. Advance the biopsy needle introducer sheath into a hepatic vein using the same technique as described in 3.4.
4. Depending on the biopsy set used, proceed either to step 6.1 for aspiration TJBX or to step 7.1 for core TJBX.

6. Transjugular aspiration liver biopsy

1. Use a 10 mL Luer-lock syringe to flush the aspiration TJLBX needle with sterile saline, however, leave about 3 mL in the syringe to facilitate aspiration.
2. Advance the biopsy needle gently through the biopsy needle introducer sheath until the tip of the needle reaches the end of the introducer sheath.
   NOTE: Avoid any force or fast movements while advancing the needle. Asking the patient to take a deep breath will decrease the angle between the IVC and the hepatic veins for easier advancement of the biopsy needle.
3. Ask the patient to hold his breath.
4. Apply suction using the 10 mL Luer-lock syringe and advance the needle into the liver parenchyma.
5. Retract the needle while still applying suction (negative pressure).
6. Advice the patient to continue breathing normally.
7. Remove the needle (but not the needle introducer sheath) and harvest the liver sample.
   NOTE: The liver sample is usually retained in the syringe, not in the needle (Figure 4D).
8. Repeat steps 6.1 to 6.6 for additional needle passages until sufficient liver specimens are obtained.
9. Inject 5-10 mL of contrast media over the catheter introducer sheath to rule out perforation of the liver capsule.
10. Remove the biopsy needle introducer sheath.
11. Remove the 10 F liver biopsy set introducer sheath and apply pressure on top of the vascular insertion site of the internal jugular vein for at least 5 min using sterile gauzes.

7. TRANSJUGULAR CORE LIVER BIOPSY

1. Load the core TJLBX needle by pulling the grip until the shooting mechanism is locked. Advance the core biopsy needle gently through the biopsy needle introducer sheath until the tip of the needle approaches the end of the introducer sheath.
   NOTE: Avoid any force or fast movements while advancing the needle.
2. Ask the patient to hold his/her breath.
3. Advance the needle into the liver parenchyma.
4. Perform the core biopsy by pulling the trigger of the shooting mechanism.
5. Advice the patient to continue breathing normally.
6. Remove the needle (but not the needle introducer sheath) and harvest the liver sample. A small needle might help to remove the liver sample (Figure 4D).
7. Repeat steps 7.1 to 7.6 for additional needle passages until sufficient liver specimens are obtained.
8. Inject 5-10 mL of contrast media over the side port of the catheter introducer sheath to rule out perforation of the liver capsule.
9. Remove the biopsy needle introducer sheath.
10. Remove the 10 F liver biopsy set introducer sheath and apply pressure on top of the vascular insertion site of the internal jugular vein for about 5 min using sterile gauzes.

In compensated patients with well-preserved liver function (i.e. without any history of hepatic decompensation, such as ascites or variceal bleeding) the measured HVPG values might be normal or in the range of subclinical portal hypertension (HVPG 6–9 mm Hg). However, compensated patients might develop CSPH (HVPG ≥10 mm Hg) which indicates an increased risk for developing varices or hepatic decompensation. In turn, patients with esophageal or gastric varices, HVPG is usually in the range of CSPH, if not patients should be assessed for the presence of portal vein thrombosis or other reasons for prehepatic/presinusoidal portal hypertension. In patients with a history of bleeding from esophageal varices, HVPG is usually at least ≥12 mm Hg. Similarly, in patients with ascites due to cirrhosis, i.e., portal-hypertensive ascites, the HVPG values are usually expected to be at least ≥10 mm Hg (Figure 3E). HVPG values of ≥20 mm Hg indicate high risk of failure to control bleeding and/or recurrent variceal bleeding and patients should be candidates for preemptive transjugular intrahepatic portosystemic shunt (TIPS) placement, if they develop variceal bleeding. While HVPG values might rise to values >30 mm Hg in patients with advanced cirrhosis and severe portal hypertension, HVPG values of >40 mm Hg are very unusual and the accuracy of the measurement and the pressure tracings should be critically assessed.

Very high values of FHVP and IVC may hint to incorrect calibration of the pressure transducer but might also indicate right heart failure or tricuspide valve regurgitation. A difference of more than ≥4mm Hg between the FHVP and the IVC pressure is suggestive of an outflow obstruction/stenosis of the hepatic vein or Budd-Chiari Syndrome. However, in case of severe Budd-Chiari Syndrome with complete thrombotic obstruction of the hepatic veins, the insertion of the balloon catheter is usually not possible. Thus, in case Budd-Chiari Syndrome or other causes of hepatic outflow obstruction are suspected, a Doppler ultrasound examination of the hepatic veins is recommended.

If shunts are observed during contrast media injection while the balloon is inflated, the HVPG is typically underestimated. However, while in this case the absolute value of HVPG cannot be used to estimate prognosis or guide pharmacological therapy, the diagnosis of CSPH can still be made if the HVPG is recorded at ≥10 mm Hg.

In primary prophylaxis of variceal bleeding, hemodynamic response to non-selective betablocker therapy (e.g. with carvedilol 12.5 mg once daily) is defined as an HVPG decrease of at least ≥10% compared to baseline, or as a decrease to absolute values <12 mm Hg: e.g., patient A (who had no previous episode of variceal bleeding) has a baseline HVPG of 20mm Hg. Following administration of carvedilol 12.5 mg/day for 4 weeks, a second HVPG (on carvedilol) of 16 mm Hg is recorded. Thus, HVPG decreased by 4 mm Hg (i.e. 20% of baseline HVPG), indicating a hemodynamic response.

In secondary prophylaxis of variceal bleeding, hemodynamic response requires an HVPG decrease of ≥20% (or to absolute values <12 mm Hg): e.g., patient B has a baseline HVPG of 26 mm Hg and under propranolol 40 mg b.i.d. (80 mg cumulative daily dose) HVPG drops to 24 mm Hg, which is a decrease of just 8%, indicating hemodynamic non-response. In absence of a hemodynamic response, patient B has a high risk of rebleeding if treated with propranolol 40 mg b.i.d only.

It has been shown that HVPG-guided pharmacological therapy plus endoscopic band ligation is more effective than ‘uncontrolled‘ combined therapy of NSBB plus endoscopic band ligation in secondary prophylaxis and even improved survival³².

Transjugular liver biopsy can be safely performed in the same session using the same vascular access sheath after recording HVPG. Liver biopsy specimens obtained with transjugular aspiration biopsy needles might be fragmented, especially in patients with cirrhosis, and thus, less representative than biopsies obtained with core biopsy needles. However, in patients in whom less pronounced liver fibrosis is expected, aspiration needle biopsy yields good sample quality with usually larger diameter specimens being obtained.

Figure 1: Equipment needed for a hepatic hemodynamic laboratory. (A) Room dedicated/approved for procedures using x-ray with a digital x-ray fluoroscope system. (B) Monitor system for vital signs, i.e., ECG, non-invasive blood pressure, and oxygen saturation. (C) Pressure transducer with pressurized sterile saline flush. (D) Ultrasound device for guiding vascular access. (E) Sterile working area. Please click here to view a larger version of this figure.

Figure 2: Sterile equipment needed for HVPG measurement. This figure shows the sterile working area prepared with the materials needed for (A) central venous access and (B) placement of the balloon catheter in a hepatic vein. Please click here to view a larger version of this figure.

Figure 3: Placement of the catheter introducer sheath and correct positioning of the balloon catheter. (A) Catheter introducer sheath correctly placed in the right internal jugular vein. (B) Balloon cather advanced into the IVC. (C) Balloon catheter advanced into the right hepatic vein. (D) Balloon catheter with inflated balloon and hepatic vein visualized by contrast media injection. (E) Representative pressure tracing of the free and wedged hepatic pressure readings. Please click here to view a larger version of this figure.

Figure 4. Equipment needed for transjugular liver biopsy. (A) 10 F transjugular liver biopsy set introducer sheath. (B) Transjugular aspiration biopsy system including the biopsy needle introducer sheath and the transjugular aspiration biopsy needle connected to a 10 mL Luer-lock syringe. (C) Transjugular core biopsy system including the needle introducer sheath with a side port and the core biopsy needle. (D) Liver specimen obtained by transjugular biopsy. Please click here to view a larger version of this figure.

While HVPG measurements require considerable resources and trained personal with interventional skills and expertise in the reading of pressure tracings, it improves prognostication and might guide treatment decisions, and thus, facilitates personalized medicine. In addition, the opportunity to safely obtain liver biopsy specimens via the transjugular route in the same session is another argument in favor of implementing hepatic hemodynamic laboratories at tertiary care centers. Indeed, guidelines support the use of HVPG measurements in centers with adequate expertise and resources^2,4. The safety of the procedures is largely related to the vascular access to the internal jugular vein. Once correctly placed, the risk of the remaining procedure is negligible and patient’s comfort is mostly limited by the duration of the procedure, if placement of the balloon catheter in the hepatic vein takes longer as expected. While a recently published study on patient-reported outcomes demonstrated that the HVPG procedure is well-tolerated⁴¹, low dose midazolam sedation (up to 0.02 mg/kg body weight) may be used to relief anxiety and to promote patient comfort⁴². However, general anesthesia and/or deep-sedation with propofol and remifentanil cannot be used for HVPG measurements, since this would impact on hemodynamic readouts⁴³.

In case the right internal jugular vein cannot be used for venous access (e.g. in case of thrombosis), the left internal jugular vein or alternative vessels may be used instead. Importantly, HVPG can also be measured via the femoral veins given specialized catheters are used.

However, the most critical part of HVPG measurements is the correct recording of pressure tracings while the balloon is insufflated and deflated, ensuring that proper placement and sufficient time are assured to obtain the correct WHVP and FHVP. The waveforms obtained in the "free" position of the catheter might be slightly impacted by the heart beat or a physiologic tricuspid valve regurgitation during systole, however, should still follow a straight line. In contrast the "wedged" pressure curve obtained when the balloon is inflated should follow a fast increase during the first 3-5 s followed by a more slowly increase over 10-30 s. Finally, a straight and stable line should be obtained which reflects the correct sinusoidal pressure. Any inconsistencies occurring during triplicate measurements should prompt the operator to obtain additional pressure readings in order to identify the correct FHVP and WHVP.

The complication rate of HVPG measurement is low and the risks are almost exclusively related to the venous access usually performed at the right internal jugular vein^11,13. Common side effects of the HVPG procedure that should be discussed with the patients prior to the procedure include pain at the insertion site or slight thoracic or abdominal discomfort when advancing the catheter through the vena cava system into the hepatic veins and while inflating the balloon. Specific but rare complications related to the venous access include hematomas at the access site, pneumothoraces requiring a chest tube and cardiac arrhythmias.

The four main indications for HVPG measurements are (i) to establish the diagnosis of intrahepatic portal hypertension, (ii) to identify patients at risk for hepatic decompensation by diagnosing CSPH (HVPG ≥10 mm Hg), (iii) to guide pharmacological therapy in primary or secondary prophylaxis of variceal bleeding, and (iv) assess the risk of hepatic failure after partial hepatectomy. While CSPH diagnosis and risk stratification might also be performed by imaging/laboratory studies or by endoscopy^2,44, currently, there are no adequate alternative means to monitor the response to NSBB therapy. While some patients might be readily excluded from major hepatic resection by considering signs of hepatic impairment (i.e. ascites or jaundice)⁴⁵, measurement of HVPG represents an important predictor of postsurgical morbidity and mortality in patients with otherwise well-preserved liver function (i.e. compensated patients)⁴⁶.

HVPG correlates well with directly measured portal pressure (or more precisely, the pressure gradient throughout the liver), as it has been shown for patients with alcoholic and viral etiology of liver disease⁹. However, certain liver diseases (e.g. nodular regenerative hyperplasia) might also affect presinusoidal resistance which impacts on the severity of portal hypertension but is not adequately reflected by HVPG⁴⁷. Furthermore, HVPG is also not able to detect the presence of (additional) prehepatic portal hypertension, as caused by portal vein thrombosis or mechanical compression of the portal vein. Thus, abdominal imaging with a special focus on the splenoportal vascular axis, on the mesenteric veins, as well as on spleen size and the presence of ascites should be performed in unclear cases and whenever a prehepatic component of portal hypertension is suspected⁴⁸.

Finally, the use of transjugular liver biopsy has been demonstrated to be safe in patients with contraindications for percutaneous liver biopsy, e.g., due to inherited or acquired bleeding disorders or in case of severe ascites^49,50. In addition, the development of core biopsy needles has increased the diagnostic yield of TJBX^51,52. In case of acute liver failure of unknown etiology, or in case of suspected cirrhosis, transjugular biopsy should be favored over percutaneous liver biopsy for safety reasons in most cases. In decompensated patients, percutaneous liver biopsy is associated with considerable risks of severe bleeding or procedure-related complications, while in compensated patients, the respective risks are lower. Still, we prefer to perform TJBX in all patients with cirrhosis (including compensated patients) as important prognostic information through HVPG measurements can be simultaneously obtained.