Outcomes of a Modified Portal Venovenous Bypass Technique During Liver Transplantation in High‐MELD Recipients

BACKGROUND: Although portal (venovenous) bypass (pVVB) is uncommon in liver transplantation (LT), it may provide some advantages, particularly for high-acuity recipients. METHODS: To examine its use in high-risk patients, we retrospectively evaluated outcomes of a modified pVVB technique among adult LT recipients at a single center, stratified by MELD score (≥35 vs. <35). Primary outcomes were patient and graft survival evaluated withKaplan-Meier estimates and multivariable Cox regression; secondary outcomes included biliary complications, transfusion requirements, viscoelastic parameters, laboratory trends, length of stay, readmission, and need for dialysis. RESULTS: Between January 2016 and July 2025, 548 patients underwent LT with pVVB; 111 (20.3%) had MELD ≥35. Despite greater baseline severity, higher transfusion requirements, and longer postoperative ICU stay, MELD ≥35 was not associated with increased risk of graft failure (HR 1.19; 95% CI 0.72-1.96), mortality (HR 0.86; 95% CI 0.46-1.61), or biliary complications (HR 1.02; 95% CI 0.65-1.60). Post-reperfusion viscoelastic measures were similar across groups. Dialysis was more frequent before and after LT in MELD ≥35. No complications or deaths were attributable to pVVB. CONCLUSION: Among LT recipients treated with pVVB, MELD ≥35 was not significantly associated with graft failure, mortality, or biliary complications. These findings support the feasibility of pVVB in high-acuity recipients.