Successful liver transplantation after endovascular recanalization of chronic portal vein thrombosis: a case report

Portal vein thrombosis (PVT) complicates liver transplantation and was historically considered a contraindication due to its impact on graft function. Recent advances have shifted this view, recognizing chronic PVT as a challenging but manageable condition. We report a 42-year-old man with chronic PVT and decompensated cirrhosis who was referred under the assumption that transplantation was not possible. However, endovascular intervention to recanalize the portal vein offered a potential solution. Preoperative imaging revealed complete thrombosis of the right portal vein and the superior mesenteric vein (SMV). Two weeks before transplantation, a transhepatic intervention restored portal venous flow using balloon angioplasty. Transjugular intrahepatic portosystemic shunt (TIPS) was considered but was not feasible because of anatomical challenges. After thrombectomy and portal vein anastomosis during transplantation, significant SMV stenosis was identified intraoperatively. This stenosis was treated with stenting and balloon dilatation. Postoperative anticoagulation with apixaban was initiated. Three months later, follow-up imaging confirmed patency. This case demonstrates the utility of transhepatic recanalization for managing chronic PVT and facilitating successful liver transplantation without TIPS. Furthermore, it underscores the importance of multidisciplinary collaboration in complex transplant cases.