Pediatric living donor liver transplantation for small infants with biliary atresia using interposition portal vein grafts, multi-center cohort study

Background: Despite multiple techniques, portal vein (PV) inflow reconstruction during living donor liver transplantation (LDLT) for patients with biliary atresia (BA) and small-diameter PV remains a challenge. The use of PV interposition grafts has emerged as a promising therapeutic strategy to mitigate complications and reinterventions. Methods: We conducted a retrospective multi-center cohort study of patients under 3 years of age (n=85) undergoing LDLT for biliary atresia using PV interposition grafts. Our primary outcome was PV complications after LDLT, and secondary outcomes included long-term PV patency and death-censored graft survival. Results: LDLT was performed on 85 patients. The PV diameter was 4.0±0.6 mm. Cold-stored venous allografts were used in 26 cases, donor-derived grafts in 53, and autologous in six. The portal inflow was the PV in 38 cases, splenomesenteric confluence in 33, superior mesenteric vein in 3, and coronary vein in 1. The intraoperative PV thrombosis rate was 22.4% and the overall PV complication rate after LDLT was 23.5% (16 PV stenoses and 4 thromboses). Multivariate analysis revealed that the use of cold-stored venous allografts predicted PV complications (53.8% vs. 10.2%; RR, 15.9; 95%CI 2.9-86.2; p =0.001). Eleven patients underwent PV stent placement after LDLT with primary patency rates of 81.8% and secondary patency rates of 90.9%. The Long-term patency, death-censored graft survival, and patient survival rates were 96.5%, 96.5%, and 97.6%, respectively. Conclusions: Portal inflow reconstruction using interposition grafts during LDLT for biliary atresia achieves favorable long-term patency and patient and graft survival outcomes. This approach has the potential to mitigate morbidity and mortality in pediatric BA patients undergoing LDLT. Longer cold-stored venous allografts are associated with a higher risk of PV complications after LDLT.