Double-Access Strategy for Chronic Portal Vein Thrombosis: Salvage Recanalization via Transsplenic and Transhepatic Routes

Chronic portal vein thrombosis (PVT) with cavernous transformation is a rare but serious complication after liver transplantation, often associated with portal hypertension and gastrointestinal (GI) bleeding. We report the case of a 47-year-old female liver transplant (LT) recipient with recurrent bleeding and imaging findings of chronic PVT. Despite extensive evaluation, no active bleeding source was identified. Given persistent symptoms and portal hypertensive changes, portal vein recanalization (PVR) was attempted. A combined transhepatic and transsplenic approach enabled through-and-through access across the occlusion. Sequential balloon angioplasty and deployment of a covered stent with overlapping bare-metal stents restored portal venous flow and reduced collateral circulation. Technical success was achieved, with no major complications apart from a self-limited perisplenic hematoma managed with embolization. This case demonstrates the feasibility and effectiveness of a dual-access endovascular strategy for complex chronic PVT with cavernous transformation in post-transplant patients.