Preoperative Portal Vein Thrombosis Grading Predicts Post-Transplant Thrombosis and Survival

Previous studies have suggested an association between preoperative portal vein thrombosis (PVT) and post-transplant PVT occurrence, but comprehensive evidence evaluating the impact of thrombosis severity grading remains limited.

To investigate the influence of preoperative PVT grading on cumulative PVT occurrence time and survival outcomes following liver transplantation.

This retrospective cohort study consecutively enrolled patients undergoing deceased donor liver transplantation between April 2020 and October 2023. All patients underwent dual-modality imaging assessment (Doppler ultrasound combined with contrast-enhanced CT/MRI) for PVT grading according to the Yerdel classification. A standardized anticoagulation protocol was implemented postoperatively. Statistical analyses included Kaplan-Meier curves for cumulative incidence, Fine-Gray competing risk models adjusting for death as a competing event, multivariable Cox regression analysis, and comprehensive sensitivity analyses.

Among 126 enrolled patients, the preoperative PVT grading distribution showed significant differences in cumulative post-transplant PVT risk (Grade 0: 14.3%, Grade I: 52.4%, Grade II: 71.4%, Grade III: 85.7%, p<0.001). Fine-Gray competing risk analysis confirmed grading as an independent predictor after adjusting for death (subdistribution hazard ratio [sHR] for Grade III vs Grade 0: 6.24, 95% CI: 3.81-10.21, p<0.001). The combined predictive model incorporating PVT grading, donor factors, and ALBI score achieved superior discrimination (1-year AUC: 0.876; 2-year AUC: 0.843) compared to binary PVT assessment alone (1-year AUC: 0.739, p<0.001). Tertile-based risk stratification revealed significant differences in 3-year survival rates (high-risk: 76.2%, intermediate-risk: 88.1%, low-risk: 95.2%, p<0.001).

Preoperative PVT grading represents a crucial predictor of cumulative PVT risk and survival differences after liver transplantation. Implementation of dual-modality imaging assessment and risk-stratified anticoagulation protocols may optimize post-transplant outcomes.