Portal Steal During Liver Transplantation in a 31-Year-Old: When Absent Varices Signal Extensive Splenorenal Shunting

Extensive portosystemic shunting in portal hypertension creates a paradox: effective decompression protects against variceal bleeding but complicates liver transplantation through portal steal. We report a 31-year-old man with cryptogenic acute-on-chronic liver failure grade 3 (Model for End-Stage Liver Disease-Sodium (MELD-Na) 31, United Kingdom Model for End-Stage Liver Disease (UKELD) 63). Despite severe portal hypertension on Doppler ultrasound, endoscopy revealed complete absence of oesophageal and gastric varices. CT explained this paradox, demonstrating a large tortuous splenorenal shunt providing highly effective decompression. At transplantation, this protective adaptation caused portal steal, with immediate right posterior sector graft demarcation. Restoration of perfusion required emergent left renal vein ligation. This case highlights how extensive splenorenal shunting can fully mask varices yet create critical intraoperative challenges. The absence of varices in established portal hypertension should prompt investigation for alternative drainage pathways. Even in young patients, comprehensive vascular assessment is essential, as protective anatomical adaptations can precipitate life-threatening operative emergencies requiring specialized surgical intervention.