Temporary Portocaval Shunts During Liver Transplantation: A Narrative Review of Technical Solutions and Post-Transplant Outcomes

<b>Background</b>: Liver transplantation (LT) continues to evolve with techniques aimed at minimizing perioperative complications associated with caval and portal vein clamping. Caval-sparing approaches, such as the piggyback technique, preserve hemodynamic stability; however, portal clamping remains necessary and may trigger postreperfusion syndrome, endotoxemia, and hepatic microcirculatory disturbances. Temporary portocaval shunts (PCSs) have been developed to maintain portal flow during LT, mitigating these adverse effects and allowing for hemodynamic stability and a reduced intraoperative bleeding. <b>Portocaval Shunts</b>: Various PCS techniques-including end-to-side, right-branch, portosaphenous, mesenterico-saphenous, iliac-venous conduit interposition, portoumbilical, and Rex-saphenous shunts-allow an individualized approach based on patient anatomy and surgical complexity. <b>Review of Evidence</b>: Available evidence demonstrates that PCS improves intraoperative hemodynamic stability, reduces blood transfusion requirements, and preserves renal function, particularly in patients with high portal flow or severe portal hypertension. PCS may also shorten warm ischemia time, facilitate hepatectomy, and enhance outcomes in extended criteria donor grafts or marginal organs. Meta-analyses and randomized studies support its role in reducing intraoperative blood loss, improving early graft function, and accelerating postoperative recovery. However, the effect of PCS on long-term survival and major postoperative morbidity remains variable, likely due to heterogeneity in patient populations, donor types, and perioperative management. <b>Conclusions</b>: Overall, PCS represents a safe and feasible adjunct in LT, offering significant hemodynamic and technical advantages. Its use should be individualized based on patient risk factors, intraoperative hemodynamics, and anticipated intraoperative challenges. PCS provides a practical strategy to preserve portal flow, minimizing intraoperative complications and facilitating the hepatectomy. However, the decision to create a PCS during LT still depends on the surgeon's preference. Postoperative outcomes and impact on long-term survival require further investigation.