Thinking outside the box: leveraging endoscopic ultrasound–guided portal pressure gradient for comprehensive risk stratification in liver transplantation candidates

Background and Aims: Coronary artery disease (CAD) is common in liver transplantation (LT) candidates and may require coronary artery bypass grafting (CABG). Risk stratification is challenging in cirrhosis because histology alone does not reliably predict clinically significant portal hypertension (CSPH). Endoscopic ultrasound–guided portal pressure gradient (EUS-PPG) provides minimally invasive, real-time hemodynamic assessment. The aim of this study was to evaluate the role of EUS-PPG in perioperative risk stratification among LT candidates requiring CABG. Methods: We retrospectively reviewed 3 LT candidates with hepatocellular carcinoma (HCC) as the indication for transplant (2021-2023). All had obstructive multivessel CAD not amenable to percutaneous coronary intervention and were evaluated for CABG using EUS-PPG when feasible. Results: Two patients with biopsy-proven cirrhosis had PPG <6 mm Hg, excluding CSPH; both underwent CABG and successful LT. In 1 patient, PPG could not be obtained because of anatomical distortion; CABG proceeded urgently, but the patient died postoperatively from stroke and aspiration pneumonia, which were unrelated to portal hypertension. Conclusions: EUS-PPG may be safe and clinically informative, complementing the Model for End-Stage Liver Disease–based risk stratification and histology to refine perioperative risk assessment in LT candidates with HCC and CAD, although additional cases and further study are needed.