Management of extensive portal vein thrombosis in adult living donor liver transplantation: the first case report from Indonesia

Extensive portal vein thrombosis (PVT) remains a significant technical challenge in living donor liver transplantation (LDLT). We report the first adult LDLT in Indonesia performed in the presence of extensive portomesenteric thrombosis (Yerdel grade IV), highlighting the surgical approach and outcome. A 45-year-old man with decompensated end-stage liver disease due to chronic hepatitis C underwent LDLT using a right lobe graft from an unrelated donor (graft-to-recipient weight ratio, 0.79%). Preoperative imaging revealed chronic thrombosis involving the main portal vein, superior mesenteric vein, and splenic vein. The 800-minute procedure included stepwise eversion thrombectomy using the pullout technique, autologous portal vein reconstruction, and temporary portocaval shunting during a 270-minute anhepatic phase. Portal inflow was successfully restored, and intraoperative Doppler confirmed patent vascular anastomoses. Serial postoperative imaging demonstrated sustained portal vein patency without rethrombosis. Combining eversion thrombectomy with the pullout technique enabled complete portal revascularization while preserving native venous anatomy and maintaining hemodynamic stability. Extensive PVT in adult LDLT can be managed effectively with tailored surgical strategies, supporting the feasibility of complex LDLT in developing transplant programs.