Comparison of computed tomography and portal venography in children with chronic extrahepatic portal vein obstruction

Abstract Background In pediatric chronic extrahepatic portal vein obstruction (EHPVO), contrast-enhanced computed tomography (CECT) may provide suboptimal visualization of intrahepatic portal vein (PV) branches and may therefore underestimate suitability for recanalization. Percutaneous portal venography (PVG) may provide more complete intrahepatic detail. Purpose To compare CECT and PVG for visualization of intrahepatic portal branches relevant to recanalization in children with chronic EHPVO and to explore whether a CECT “beak sign” is associated with technical success. Materials and methods This single-center retrospective study (2018–2024) included children with non-cirrhotic, non-malignant chronic EHPVO who underwent preprocedural CECT and percutaneous PVG during attempted PV recanalization. Right/left PV and segmental branches (2/3 combined, 4, and 5–8) were scored visible/not visible. The beak sign was defined as a sharply tapered extrahepatic PV stump ending at the occlusion site. Technical success was restoration of hepatopetal portal flow after crossing the occlusion and balloon angioplasty. Results Eighteen of 51 screened patients were included (median age, 7 years); technical success was achieved in 14/18 (77.8%). PVG visualized intrahepatic portal branches more frequently than CECT across segments; segment-level paired comparisons were considered exploratory given the small cohort and limited discordant pairs. The beak sign was present in 10/18 (55.6%) and was not significantly associated with technical success. Conclusion PVG may provide more complete delineation of intrahepatic portal venous branches than CECT in pediatric chronic EHPVO; therefore, absent intrahepatic visualization on CECT alone should not preclude referral for recanalization evaluation. The beak sign is hypothesis-generating and warrants validation in larger cohorts.