*Purpose: Acute portal venous thrombosis (PVT) in perioperative period after living donor liver transplantation (LDLT) in pediatric patients is a serious complication. It can lead to increased morbidity, graft loss, and patient death if not diagnosed and treated promptly. Surgical options for acute PVT are surgical re-exploration and revision of the anastomosis, intraportal thrombolytic therapy, percutaneous angioplasty or re-transplantation in patients with graft failure. Thrombectomy through re-opened umbilical vein has been rarely reported. Herein we present experience of three pediatric LDLT recipients that developed acute PVT in immediate intraoperative period and were treated by re-opened umbilical vein approach.

*Methods: From May 2017 till December 2019, a total of 102 liver transplantations were performed at our institutions. The database of pediatric LDLT patients (n=35) was analyzed and 5 patients that developed acute PVT or portal flow abnormalities in perioperative period was further studied.

*Results: Five pediatric patients [median age 8 months (range, 6 months to 10 years); Male: Female, 4:1] underwent LDLT using left lateral liver graft. Four patients in this series had acute PVT within 24 hours of LDLT that was detected during protocol ultrasound examination in the background of elevated lactates and liver enzymes whereas in one patient the acute PVT was intraoperatively after reperfusion. First, patient underwent re-exploration and revision of anastomosis, but continued to have reduced portal flow.For remaining four patients, the umbilical vein was re-opened and access to main portal vein was established. All the patients had thrombus at the anastomotic site. Thrombectomy was done via re-opened umbilical vein without disturbing the anastomosis. Backflow through umbilical vein confirmed establishment of the portal flow. However, due to angulation at the anastomosis, there was intermittent reduction of portal blood flow. Therefore, intraportal self-expanding vascular stent was placed in both patients. The position and patency were checked before closing the abdomen using fluoroscopy. All the 4 patients that underwent portal vein stenting showed uneventful postoperative coarse till discharge from the hospital with stable liver graft functions.

*Conclusions: Acute PVT in immediate post-LDLT period is a major complication that may lead to graft loss. Early diagnosis and hybrid technique of open surgery with insertion of portal vein stent by interventional radiology can establish adequate portal venous flow without need of complex revision of porto-portal anastomosis. Re-canalization of the umbilical vein of the liver graft is a feasible approach for portal thrombectomy as well as for the insertion of vascular stents across portal anastomosis to prevent kinking and inflow disturbances.

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