Management of Preoperative Recipient Portal Vein Thrombosis in Living-donor Liver Transplantation

Portal vein thrombosis (PVT) occurs as a part of the natural history of cirrhosis in up to 15% of patients with cirrhosis. In the initial days, PVT was considered a contraindication to liver transplantation, but now with advanced techniques and perioperative management, patients with complex PVT also undergo living-donor liver transplantation (LDLT) with a similar outcome. This review provides a comprehensive overview of methods to proceed with liver transplantation when the recipient has PVT. Preoperatively, anticoagulation remains the mainstay of treatment, with transjugular intrahepatic portosystemic shunt (TIPS) playing an adjunct role in preparing patients for liver transplantation. In all patients, thrombectomy with re-establishment of physiological portal flow is the initial step. In patients where flow cannot be established, other physiological or nonphysiological means are employed, especially in complex PVT. Patients with grade III/IV PVT have worse outcomes (graft failure, mortality, recurrence) than those with lower-grade PVT. Physiological reconstruction is the method of choice, whereas non-physiological means are used as a bailout procedure.