Applying Intraoperative Portal Venography in Liver Transplantation Vascular Surgery

<b>Background/Aim:</b> Adequate portal inflow is essential for liver graft regeneration following transplantation. Intraoperative portal venography (IOPV) provides real-time assessment of portal vein patency, stenosis, thrombus formation, and portosystemic collaterals. In addition to imaging, portal vein pressure gradient (portal vein pressure minus inferior vena cava pressure) was also measured. This study assessed the impact of IOPV on surgical decision-making and post-transplant outcomes to establish criteria for patient selection. <b>Methods:</b> From November 2016 to November 2024, 34 liver transplant patients with portal inflow insufficiency (flow velocity < 10 cm/s), large shunts (>1 cm), or portal vein thrombosis underwent IOPV. Of the patients, one received deceased donor liver transplantation (DDLT), and the others received living donor liver transplantation (LDLT). Preoperative computed tomography (CT) and ultrasound (US) assessed portal vein patency, thrombus, and shunts. Postoperative US and CT monitored portal flow and graft regeneration. <b>Results:</b> IOPV influenced surgical planning in all cases, leading to shunt ligation or stenting, and improved portal vein flow velocity from 6.3 (IQR, 0-9.0) to 30.8 (IQR, 22.2-36.7) cm/s (<i>p</i> < 0.001). Adequate inflow was achieved in 32 patients, 2 had persistent low flow or occluded flow owing to severe adhesion after transplant and failure to close large collateral veins. Graft regeneration ranged from 104% to 255% within a year. <b>Conclusions:</b> IOPV is a valuable tool in liver transplantation vascular surgery, optimizing surgical strategies and portal inflow. Early integration into routine practice may improve graft outcomes. Further prospective, longitudinal research is needed to refine patient selection and assess long-term benefits.