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The management of portosystemic shunts in liver transplant recipients relies on appropriate perioperative study. There are several strategies for shunt handling, ranging from preoperative interventional procedures to intraoperative surgical interruption or embolization. Appropriate management often results in a successful outcome, although wrong decisions could lead to serious consequences. Here, we report a liver transplant recipient with grade 2 portal vein thrombosis associated with 2 large portosystemic shunts (coronary and mesocaval), which were managed intraoperatively via thrombectomy without shunt ligation. Acute portal vein thrombosis developed early after transplant due to portal steal syndrome. The patient underwent a successful endovascular shunt embolization, with prompt restoration of hepatopetal portal flow and resolution of the portal steal. Use of interventional radiology in perioperative management of transplant patients has recently gained wider importance; our case reported here is particularly suggestive of the good outcomes of a multidisciplinary approach to a threatening complication such as postoperative acute portal vein thrombosis.

The shortage of organs has pushed transplant surgeons to accept liver grafts with extended criteria, but severe vascular abnormalities may still discourage the use of otherwise acceptable organs. We report herein the case of a liver graft with a 64-mm aneurysm of the proper hepatic artery extended to the origin of the right and left hepatic branches. The graft was deemed unsuitable for transplant by all other centers in the region. However, liver function tests were normal, and there was no evidence of compromised arterial supply. At back table, we resected the aneurysm and anastomosed the right and left hepatic arteries to a vascular graft obtained from the distal tract of the donor's superior mesenteric artery. After portal reperfusion, we anastomosed the mesenteric graft to the recipient's hepatic artery at the origin of the gastroduodenal artery. The postoperative course and the subsequent 6-month follow-up were uneventful. In conclusion, the presence of a hepatic artery aneurysm should not be an absolute contraindication to the use of a liver graft. The present case emphasizes the possibility to utilize an organ that would have been otherwise discarded.