The management and outcomes of De Novo Portal Vein thrombosis following liver transplantation

• De novo portal venous thrombosis can compromise long term allograft outcomes. • Complete resolution can be successfully achieved with medical management only. • Surgical interventions should be reserved for early thrombosis with threatened grafts. While portal vein thrombosis (PVT) is well described in patients with cirrhosis, no guidance on de-novo cases following liver transplantation (LT) exists. We describe our experience with new-onset PVT in liver allografts post-LT. Transplant recipients between 2002 and 2024 were reviewed from an institutional database excluding patients with pre-LT PVT. Early (<30 days) and late (>30 days of LT) PVT was defined accordingly. Out of 2273 LTs, PVT occurred in 32 recipients (age 51 ±11 years; early n=15; late n=17). Median time to PVT was 42 days (range 3– 5042 days). Complete thrombus resolution was achieved following re-transplantation (n=4) and surgical thrombectomy (n=3). Venoplasty (n=1) and stenting (n=1) were performed for late PVT events. Using anticoagulation-only strategies, complete resolution was achieved in 16/17 recipients. The remaining 6 did not receive any medical or surgical intervention. Both 1-, 3- and 5-year overall (p<0.05) and graft survival (p=0.02) were lower in LT recipients with de novo PVT when compared to non-PVT cases. Although infrequent, PVT post-LT is a difficult clinical scenario with no clear treatment algorithm in the transplant literature. Non-operative management is feasible, however, surgical and radiological interventions are merited for LT recipients with compromised allograft function.