Cirrhosis is the most advanced stage of chronic liver disease. It is usually characterized by an early asymptomatic course (compensated cirrhosis) that may be followed by the development of clinical decompensation, organ failure and hepatocellular carcinoma (HCC). Portal hypertension (PH) is the key driver for the emergence of complications and therefore the main prognostic factor in compensated patients. The gold standard technique to estimate PH is hepatic vein catheterization that allows the measurement of free (FHVP) and wedge hepatic venous pressure (WHVP).1 The pressure of the static blood column in the hepatic vein becomes equilibrated through the interconnected sinusoids with portal vein pressure. Under these conditions, the WHVP is an accurate estimate of portal pressure.1 Since FHVP is comparable to the inferior vena cava pressure (IVCP), the hepatic venous pressure gradient (HVPG: WHVP minus FHVP) is equivalent to the portocaval pressure gradient.2 The development of clinically significant portal hypertension (CSPH), defined as a HVPG ≥ 10 mmHg, is associated with an increased risk of decompensation, HCC and death.2, 3, 4, 5

Hepatic vein catheterization is useful not only for risk stratification but also for the estimation of underlying architectural damage: HVPG > 5 mmHg indicates sinusoidal hypertension, and probably significant liver disease. Finally, HVPG measurement is an essential step for surgical treatment planning of HCC and other liver tumors in cirrhosis, and nowadays it is the main indication of hepatic vein catheterization.6, 7, 8

However, several circumstances may hinder an appropriate HVPG measurement. In particular, the presence of spontaneous veno-venous collaterals between different suprahepatic veins ramifications precludes the complete vein occlusion, avoiding an adequate WHVP measurement. This condition is more common in non-cirrhotic portal hypertension, including porto-sinusoidal vascular disorder and hepatic injury secondary to oncological treatments2, 9; however, it can also be found in patients with cirrhosis or in the context of liver transplantation recipients.10 The existence of an intrahepatic porto-caval shunt also precludes HVPG measurement, as it allows a permanent decompression of the sinusoidal system. Importantly, systemic hemodynamics is characteristically altered in patients with PH. Right heart catheterization is a safe and standardized procedure that can be easily performed during the hemodynamic study and may also help in the evaluation of patients with PH. The aim of this study is to describe a technical modification of the standard procedure – using a two balloon-catheter approach – which may help to adequately assess PH in patients with veno-venous collaterals. We also describe two examples of the usefulness of right heart catheterization in the diagnostic evaluation of patients with complex liver disease.