Ectopic physiological portal vein reconstruction in liver transplantation for benign portal vein thrombosis
Original Article

Ectopic physiological portal vein reconstruction in liver transplantation for benign portal vein thrombosis

Jiyong Song ORCID logo, Guangdong Wu, Lihan Yu, Xuan Tong, Ang Li, Ziqiang Li, Jingyi Lin, Tieyan Fan, Rui Tang, Guangxun Xu, Qian Lu ORCID logo

Hepato-Pancreato-Biliary Center, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua Medicine, Tsinghua University, Beijing, China

Contributions: (I) Conception and design: All authors; (II) Administrative support: Q Lu; (III) Provision of study materials or patients: All authors; (IV) Collection and assembly of data: J Song; (V) Data analysis and interpretation: J Song; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

Correspondence to: Qian Lu, MD. Hepato-Pancreato-Biliary Center, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua Medicine, Tsinghua University, No. 168, Litang Road, Changping District, Beijing 102218, China. Email: luqian01971@mail.tsinghua.edu.cn.

Background: Benign portal vein thrombosis (PVT) presents considerable technical challenges for portal vein reconstruction (PVR) during liver transplantation (LT). This study aimed to evaluate the surgical outcomes, safety profile, and clinical feasibility of ectopic physiological portal vein reconstruction (EPPVR) at non-hilar area for patients with complex benign PVT.

Methods: We conducted a retrospective observational cohort study analyzing intraoperative parameters, postoperative complications, and survival outcomes in liver transplant recipients with benign PVT. Among 120 enrolled patients, 10 cases (8.3%) underwent EPPVR, including three varicose vein reconstructions (VVRs), one anterior transpancreatic bridge reconstruction, and five “pull-out” portal vein reconstructions (POPVRs) beneath the pancreas.

Results: Compared with conventional orthotopic physiological portal vein reconstruction (OPPVR), EPPVR was associated with significantly longer anhepatic phase (154.50±45.43 vs. 79.77±34.56 mins, P<0.001) and greater intraoperative blood loss (1,930.00±1,515.15 vs. 766.36±707.50 mL, P=0.001). Postoperatively, the EPPVR group demonstrated markedly higher rates of elevated ascitic fluid amylase (60.0% vs. 5.5%, P<0.001) and required more frequent portal vein stent implantation in surviving patients (37.5% vs. 3.9%, P=0.008). Other complication rates and perioperative survival rate were comparable between these two groups. The above trends remained consistent in the subgroup analysis of patients with Yerdel grade 2–4 PVT, although the difference in stent implantation rates lost statistical significance (37.5% vs. 10.3%, P=0.15).

Conclusions: Although EPPVR was associated with elevated perioperative risks, it did not decrease the perioperative survival rate in PVT patients. This reconstruction approach may represent a feasible alternative for complex PVT cases requiring non-standard reconstruction approaches, contingent upon thorough preoperative assessment and surgical planning.

Keywords: Ectopic physiological portal vein reconstruction (EPPVR); portal vein reconstruction (PVR); liver transplantation (LT); portal vein thrombosis (PVT)

Received: 04 November 2025; Accepted: 01 March 2026; Published online: 28 May 2026.

doi: 10.21037/tgh-2025-148

Highlight box

Key findings

• For patients in whom portal vein reconstruction (PVR) at the hilar area is unfeasible, ectopic physiological portal vein reconstruction (EPPVR) represents a relatively effective strategy for managing complex portal vein thrombosis (PVT).

What is known and what is new?

• PVT is a major clinical challenge. Its prevalence ranges from 10% to 25% in patients with advanced cirrhosis, and it affects 2.1% to 26% of patients on the liver transplantation (LT) waiting list. PVR is an essential but technically difficult part of LT surgery, especially in cases of complex PVT; the success of PVR directly affects graft viability and patient outcomes.

• For patients in whom hilar-area PVR is not feasible, EPPVR is a relatively effective strategy for managing complex PVT. Although EPPVR is associated with increased perioperative risks (such as longer anhepatic phase, more intraoperative blood loss, higher rates of postoperative ascitic fluid amylase elevation and portal vein stent requirement), it does not reduce the perioperative survival rate of PVT patients. EPPVR provides a feasible alternative for complex PVT cases that require non-standard reconstruction methods, provided that thorough preoperative evaluation and surgical planning are conducted.

What is the implication, and what should change now?

• EPPVR fills the gap in the treatment of complex PVT where conventional hilar PVR is unachievable, providing a practical salvage option for LT candidates with complex benign PVT. It avoids the poor long-term outcomes associated with non-physiological portal vein reconstruction while maintaining acceptable perioperative survival, which is of great significance for improving the prognosis of such patients.

• Preoperative management: transplant centers should incorporate routine radiological evaluation of portal venous tributaries and collateral vessels into preoperative examinations to screen potential candidates for EPPVR. Surgical planning: Standardized surgical plans should be formulated based on the Yerdel PVT grade to minimize unexpected intraoperative conversion to EPPVR, thereby reducing perioperative risks. Postoperative monitoring and intervention: For patients who undergo EPPVR, intensive postoperative surveillance of portal vein patency and pancreatic-related complications should be implemented. Early interventional stent therapy should be actively adopted for portal vein stenosis to ensure graft perfusion and long-term patient survival.

Introduction

Portal vein thrombosis (PVT) poses a significant clinical challenge, with a prevalence ranging from 10% to 25% in advanced-stage cirrhotic populations and affecting 2.1% to 26% of patients on the liver transplantation (LT) waiting list (1-3). Portal vein reconstruction (PVR) constitutes an indispensable and technically demanding component of LT surgery, particularly in cases involving complex PVT, where its successful execution directly impacts graft viability and patient outcomes (4-6). Complex PVT has even once been deemed an absolute contraindication for LT (7,8). However, for patients with end-stage liver disease, LT remains the sole life-saving option, necessitating attempts even in cases of complex PVT. The optimal approach of PVR in LT is physiological portal vein reconstruction (PPVR), which directs gastrointestinal blood flow into the donor liver’s portal vein. This method needs to ensure adequate portal perfusion to the graft while reducing the risk of thrombosis. In instances where suitable portal vessels for PPVR are absent, non-physiological portal vein reconstruction (NPPVR), such as cavoportal hemitransposition or renoportal reconstruction, have to be employed (9). However, patients undergoing NPPVR often experience poorer outcomes (10,11).

The Yerdel classification is currently the most widely used grading system for PVT (1,12). Although the Yerdel classification cannot serve as a direct basis for selecting surgical strategies, it still reflects some aspects of PVT complexity and provides some assistance in analyzing surgical difficulty (12,13). For most patients with Yerdel grade 1–2 PVT, orthotopic physiological portal vein reconstruction (OPPVR) can typically be achieved at the hilar area following thorough thrombus removal. Conversely, in some patients with complex Yerdel grade 2 PVT and the majority of those with Yerdel grade 3–4 PVT, complete thrombus removal and achieving PPVR at the hilar area become challenging (12,14). To circumvent the need for NPPVR, ectopic physiological portal vein reconstruction (EPPVR) offers a viable solution. EPPVR fully utilizes the thrombus-free tributaries of the portal venous system to accomplish PVR at unconventional sites outside the hilar area. The success of EPPVR hinges on meticulous preoperative evaluation and planning, underscoring the importance of these preparatory steps in achieving favorable outcomes. We present this article in accordance with the STROBE reporting checklist (available at https://tgh.amegroups.com/article/view/10.21037/tgh-2025-148/rc).

Methods

Patient cohorts

From January 2018 to December 2024, EPPVR were performed in 10 patients with complex PVT in our center. This is a single-center experience study. The preoperative clinical characteristics of these 10 patients are detailed in Table 1. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was exempted from approval by Ethics Committee of Beijing Tsinghua Changgung Hospital as this medical diagnosis or treatment is considered safe, and informed consent was taken from all the patients.

Table 1

Preoperative clinical characteristics patients undergoing EPPVR

No. Sex Age (years) BMI (kg/m2) MELD score Primary disease Yerdel grade History of GI bleeding History of splenectomy TIPS history History of portacaval shunt
1 Male 56 28.4 12 HCC 3 Yes No No No
2 Male 51 25.6 13 HCC 2 No No No No
3 Male 67 20.8 7 Cirrhosis 3 No Yes No No
4 Male 48 26.2 16 HCC 2 No No No Yes
5 Male 37 21.3 15 Cirrhosis 2 Yes No No Yes
6 Female 23 21.6 29 Cirrhosis 2 No No Yes No
7 Female 58 19.8 7 HCC 3 No No No Yes
8 Male 66 22.2 20 HCC 2 No No No Yes
9 Male 36 31.5 26 Cirrhosis 3 Yes No No Yes
10 Female 36 21.6 26 Cirrhosis 4 Yes Yes No Yes

BMI, body mass index; EPPVR, ectopic physiological portal vein reconstruction; GI, gastrointestinal; HCC, hepatocellular carcinoma; MELD, model for end-stage liver disease; TIPS, transjugular intrahepatic portosystemic shunt.

Surgical approaches of EPPVR

Recipient’s varicose vein to donor’s PVR

Preoperative radiological imaging revealed significant venular dilatation at the hilar area of three patients—one involving a para-biliary vein and the other two gastric coronary vein. In all the three cases, the diameter of the varicose veins exceeded 10 mm. Consequently, we planned and successfully performed intraoperative anastomoses between the recipients’ varicose veins and the donors’ main portal veins (Figure 1A).

Figure 1 Surgical approaches of EPPVR. (A) Recipient’s varicose vein to donor’s portal vein reconstruction. (B) POPVR beneath the pancreas. (C) Anterior transpancreatic bridge reconstruction. EPPVR, ectopic physiological portal vein reconstruction; POPVR, pull-out portal vein reconstruction.

“Pull-out” portal vein reconstruction (POPVR) beneath the pancreas

In our series of cases, complete thrombus removal was particularly challenging in six patients, while their superior mesenteric vein had sufficient blood flow. We employed the “pull-out” reconstruction beneath the pancreas (Figure 1B). The donor’s main portal vein was pulled through the retropancreatic tunnel to its lower edge and anastomosed with the recipient’s portal vein. Among the six patients, one had a residual coil in the portal vein that could not be removed, which prompted us to leave the recipient’s main portal vein in place within the retropancreatic tunnel. The donor’s portal vein was pulled out through the tunnel’s gap, and the “pull-out” reconstruction was successfully performed.

Anterior transpancreatic bridge reconstruction

A bridging PVR across the pancreas was performed in one patient with a history of multiple abdominal surgeries (Figure 1C), as opening the retropancreatic tunnel proved challenging. In this case, the donor’s portal vein was guided across the pancreas to its lower edge and anastomosed with the recipient’s superior mesenteric vein. Postoperatively, the patient developed portal vein stenosis 17 months later, which was successfully managed with portal vein stent placement.

Statistical analysis

Descriptive statistics were adopted for baseline data, and comparative analyses of quantitative and categorical clinical outcome indicators as well as subgroup analyses were performed between groups.

Results

The perioperative course and clinical outcomes of the 10 patients undergoing EPPVR are systematically presented in Table 2. The preoperative and postoperative imaging comparisons are presented in Figure 2. Two of the 10 patients (20.0%) experienced fatal perioperative complications. Case 1 occurred postoperative gastrointestinal perforation after receiving varicose vein reconstruction (VVR). Despite surgical repair, the patient subsequently developed secondary bile leakage and abdominal infection, ultimately culminating in graft liver failure that proved fatal. The other deceased patient underwent a POPVR. Postoperatively, he experienced thoracic hemorrhage and finally succumbed to multiple organ failure after emergent thoracotomy for hemostasis. Neither of the two deceased patients was initially scheduled for EPPVR in the preoperative plan. EPPVR was adopted as an alternative due to intraoperative thrombectomy difficulties. The remaining eight patients all survived postoperatively after receiving planned EPPVR. Among the eight surviving patients, vascular complications predominated, with five cases (62.5%) developing portal vein restenosis. Three of these patients (37.5% of survivors) required endovascular stent implantation. Additional complications included acute kidney injury (AKI) in one patient (12.5%) and biliary stricture in another patient (12.5%), which were both successfully managed.

Table 2

Intraoperative and prognostic outcomes of patients undergoing EPPVR

No. PV reconstruction technique Anhepatic phase (min) Blood loss (mL) AKI Elevated amylase in ascitic fluid PV restenosis PV stent implantation Biliary complications Perioperative survival status
1 ATBR 185 4,500 No Yes Yes Yes No Alive
2 VVR 110 600 No No Yes No No Alive
3 VVR 210 4,000 No Yes Yes No Yes Died
4 POPVR 190 600 No Yes Yes No No Alive
5 POPVR 190 2,000 No Yes Yes Yes No Alive
6 POPVR 125 600 No No No No No Alive
7 POPVR 180 1,500 Yes Yes No No No Alive
8 POPVR 110 3,500 No Yes Yes No No Died
9 POPVR 170 800 No Yes No No No Alive
10 VVR 75 1,200 No No Yes Yes Yes Alive

AKI, acute kidney injury; ATBR, anterior transpancreatic bridge reconstruction; EPPVR, ectopic physiological portal vein reconstruction; POPVR, pull-out portal vein reconstruction; PV, portal vein; VVR, varicose vein reconstruction.

Figure 2 The preoperative and postoperative imaging comparisons of patients with EPPVR. (A) POPVR. (B) VVR. (C) ATBR. ATBR, anterior trans-pancreatic bridge reconstruction; EPPVR, ectopic physiological portal vein reconstruction; LT, liver transplantation; POPVR, pull-out portal vein reconstruction; VVR, varicose vein reconstruction.

Discussion

The optimal strategy for managing PVT in LT surgery entails complete thrombus removal followed by PVR at the hilar area (9,15). However, for patients with complex PVT, where complete thrombus removal is challenging, EPPVR presents a viable surgical alternative. Precise preoperative evaluation and meticulous surgical planning are critical for these cases. A key prerequisite for EPPVR is the presence of sufficient blood flow in the mesenteric vein branches and/or splenic vein branches to ensure adequate portal vein perfusion post-reconstruction. For adult patients, we recommend that the diameter of the main vessel from the recipient’s portal vein system used for reconstruction should be at least 8 mm. In cases of main portal vein occlusion, the portal vein system experiences elevated blood pressure following the disruption of varicose veins at the hilar area, which can lead to uncontrollable bleeding during thrombectomy. Thrombus removal is generally more feasible if the thrombus has formed within a year, whereas older thrombus (over 1 year) poses greater challenge (16). Thorough preoperative risk assessment and surgical planning are essential to minimize intraoperative bleeding and optimize outcomes (17,18). In our series of ten patients who underwent EPPVR, eight cases were preoperatively identified as high-risk, and tailored surgical plans were developed accordingly. These procedures were successfully executed as planned, resulting in relatively shorter anhepatic periods. However, in the other two patients, attempts to remove the thrombus were unsuccessful, necessitating a shift in surgical strategy to EPPVR. This change led to a relatively prolonged anhepatic periods and increased intraoperative blood loss, which may have contributed to postoperative mortality. For patients with exceptionally complex PVT, while NPPVR may provide temporary restoration of portal perfusion, existing evidence suggests this approach is associated with unfavorable long-term outcomes, including significantly higher mortality rates. Therefore, NPPVR should therefore be avoided whenever possible (9-11). We recommend considering multivisceral transplantation as an alternative approach for patients deemed preoperatively unsuitable for PPVR (10,19).

The POPVR technique stands as our preferred method for EPPVR. While dissecting the portal vein tunnel behind the pancreas carries inherent risks, this technique optimally preserves the original anatomical relationships and facilitates more direct portal blood return (17,20). Following reconstruction, the risk of new thrombosis or restenosis due to compression or kinking is significantly reduced. Since most of the branches are distributed bilaterally along the portal vein within the retropancreatic tunnel, initiating the opening of the retropancreatic tunnel from the anterior aspect of the portal vein is advisable. For patients in whom complete dissection of the portal vein proves challenging, we recommend ligating the thrombosed portal vein and leaving it in situ. After opening and moderately expanding the retropancreatic tunnel, the donor’s portal vein can be pulled out through the tunnel and reconstructed. In one of the six POPVR cases, this strategy was employed, leading to unimpeded portal blood flow after surgery.

For patients with thickened varicose branches in the portal vein system, it is recommended to anastomose the donor’s portal vein to these varicose branches (21-23). These thickened branches typically arise from the gastric coronary vein or the dilated collateral veins surrounding the bile duct. However, the walls of these dilated vessels are often extremely thin, making suturing technically challenging. Meticulous dissection is crucial to avoid compromising the opportunity for successful PVR. Additionally, these varicose veins may exhibit a tortuous course, which necessitates thorough preoperative and intraoperative evaluation. During the surgery, efforts should be made to straighten the vessels to minimize the risk of postoperative thrombosis. In our series, among the three patients who underwent anastomosis using thickened varicose veins, one patient experienced postoperative kinking of the varicose vein, which was successfully managed through stent placement.

Bridging the portal vein across the pancreas is another reconstruction strategy, which is similar to meso-rex bypass. But we think that it is not an optimal approach for EPPVR. Following surgery, the reduction in portal vein pressure makes the reconstructed vessel susceptible to compression by surrounding gastrointestinal or other tissues, often resulting in stenosis or occlusion. In the sole case where we employed this reconstruction, the portal vein blood flow remained unimpeded in the immediate postoperative period. However, portal vein stenosis developed 17 months after transplantation, necessitating intervention with a portal vein stent to address the complication.

In this cohort, seven patients exhibited postoperative ascitic fluid amylase elevation. It should be related with the peripancreatic dissection during the procedure of EPPVR. All the seven cases demonstrated only transient, short-term increases, with no observed adverse outcomes attributable to amylase elevation. Another noteworthy observation was that 5 of the surviving patients developed postoperative portal vein stenosis, with 3 cases (50%) requiring stent implantation. While no stenosis-related adverse outcomes were documented, these findings underscore the critical importance of maintaining vigilant surveillance of portal vein patency following EPPVR. To optimize outcomes for these patients, we recommend ligating the gastric coronary vein and any prominent porto-caval shunts following EPPVR, as this ensures adequate portal blood flow to the donor liver postoperatively.

Conclusions

In conclusion, for patients in whom PVR at the hilar area is unfeasible, EPPVR represents a relatively effective strategy for managing complex PVT.

Although EPPVR was associated with elevated perioperative risks, it did not decrease the perioperative survival rate in PVT patients. This reconstruction approach may represent a feasible alternative for complex PVT cases requiring non-standard reconstruction approaches, contingent upon thorough preoperative assessment and surgical planning.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://tgh.amegroups.com/article/view/10.21037/tgh-2025-148/rc

Data Sharing Statement: Available at https://tgh.amegroups.com/article/view/10.21037/tgh-2025-148/dss

Peer Review File: Available at https://tgh.amegroups.com/article/view/10.21037/tgh-2025-148/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tgh.amegroups.com/article/view/10.21037/tgh-2025-148/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was exempted from approval by Ethics Committee of Beijing Tsinghua Changgung Hospital as this medical diagnosis or treatment is considered safe, and informed consent was taken from all the patients.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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doi: 10.21037/tgh-2025-148
Cite this article as: Song J, Wu G, Yu L, Tong X, Li A, Li Z, Lin J, Fan T, Tang R, Xu G, Lu Q. Ectopic physiological portal vein reconstruction in liver transplantation for benign portal vein thrombosis. Transl Gastroenterol Hepatol 2026;11:65.

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