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 the reconstruction of multiple portal veins (PVs); however, there is no evidence on an ideal technique to ensure optimal inflow to the graft. In this study, we evaluate 3 different PV reconstruction techniques and compare them 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 3 techniques are safe, effective, and feasible, enabling broader safe utilization of donors with PV variations.