Efficacy of different portal vein reconstruction techniques in liver allografts with multiple portal veins in living donor liver transplantation: A propensity score matched analysis

Vascular reconstruction remains one of the most important and challenging considerations in living donor liver transplantation (LDLT)and a standard anatomy is observed in only two-thirds of the donors. Several techniques have been described for reconstruction of multiple portal vein (PV), however there is no evidence on ideal technique to ensure optimal inflow to the graft. In this study, we evaluate three different PV reconstruction techniques and compare with the outcomes of a single PV allograft in right lobe LDLT. From 2012 to 2023, 1276 right lobe LDLT recipients were reviewed, of whom 173(13.79%) had PV anatomical variations requiring reconstruction. Y- interposition graft venoplasty, conjoined unification venoplasty and graft venoplasty with extension were performed in 66 (38.2%), 51 (29.4%) and 56 (32.4%) patients respectively. Intraoperative outcomes, early postoperative outcomes and long term survival rate were comparable across techniques. Propensity score match analysis with single PV recipients revealed significantly higher early allograft dysfunction (23.8% vs. 10.9%, p=0.02) and biliary leak (14.9% vs. 5%, p=0.01) in this cohort, however vascular complications and survival rates were comparable. Overall, the findings suggest that when reconstruction is tailored to the individual vascular anatomy, all three techniques are safe, effective, and feasible, enabling broader safe utilization of donors with PV variations.