Modified Cavo-Portal Hemi-Transposition in Adult LDLT: Annals of HPB Surgery | February 2026

Introduction

Extensive porto-mesenteric thrombosis has traditionally been considered one of the most difficult situations in liver transplantation because adequate portal inflow is essential for graft regeneration and long-term function. In living donor liver transplantation, this challenge becomes even greater because the graft depends heavily on sufficient portal shear stress for recovery and growth. Although alternative inflow options such as reno-portal anastomosis, cavo-portal hemi-transposition, portal vein arterialization, and multivisceral transplantation exist, each has important technical and physiological limitations. Among these, cavo-portal hemi-transposition is well described in pediatric transplantation but remains rarely reported in adults, especially in living donor liver transplantation.

Problem Statement

In adult living donor liver transplantation, cavo-portal hemi-transposition is technically difficult because the right lobe graft portal vein is not naturally aligned with the inferior vena cava. This can lead to angulation, poor flow, thrombosis, persistent portal hypertension, and inadequate systemic venous drainage, making outcomes less favorable in adults than in pediatric patients.

Summary

This article describes an important technical modification of cavo-portal hemi-transposition in two adult living donor liver transplant recipients with diffuse porto-mesenteric thrombosis, one of whom also had Budd-Chiari syndrome. The key modification was to use the left renal vein–inferior vena cava junction as the site for inflow and to add a cryopreserved portal vein graft as an interposition conduit. This created a straighter alignment between the graft portal vein and the systemic venous inflow, while avoiding excessive mobilization of the vena cava and preserving collateral venous channels. The authors believe this improves portal inflow, reduces the risk of kinking and thrombosis, and helps maintain adequate inferior vena cava drainage. One patient had good long-term graft function after management of partial portal vein thrombosis with stenting, while the second patient died from fungal sepsis despite a patent reconstruction. Overall, the study suggests that this modified technique is a practical rescue option in highly selected adult living donor liver transplantation cases with diffuse splanchnic venous thrombosis, but it should be performed only in expert high-volume transplant centers.