Introduction
Portal vein thrombosis (PVT) after pediatric liver transplantation (PLT) is a serious complication associated with significant morbidity. It occurs more frequently in patients with portal vein (PV) anomalies, biliary atresia (BA), low recipient body weight, and graft-to-recipient weight ratio (GRWR) ≥4%. We reviewed our perioperative strategy to mitigate PVT-related morbidity.

Methods
We retrospectively analyzed 96 consecutive PLTs for BA performed between 2015 and 2025. Our preventive strategy comprised: (A) longitudinal PV venoplasty (LPVV) during transplantation if PV diameter was <6 mm; (B) serial Doppler ultrasound monitoring; and (C) prophylactic anticoagulation/antiaggregant theraphy.

Results
Kasai portoenterostomy had been performed in 79/96 patients (82.2%). Living-donor and deceased-donor grafts were used in 81 (84.4%) and 15 (15.6%) cases, respectively. Fifty-nine recipients weighed <8 kg (61.5%), and 34 had GRWR ≥4 (35.4%). Syndromic BA occurred in 9 patients (9.3%), preduodenal PV in 5 (5.2%), and PV agenesis in 1. LPVV was performed in 46/96 patients (47.9%).

Early PVT developed in 5 patients (5.2%) and late PVT in 2 (2.1%), all in those with prior Kasai and GRWR ≥4. Early diagnosis enabled prompt intervention before complications arose. Early PVT cases (5 cases) were successfully treated via interventional radiology, and late PVT (2) via Meso-Rex shunt. No graft losses were attributable to PVT. Two deaths occurred from unrelated causes, yielding 97.9% patient and graft survival at mean follow-up of 49.6 months. Chronic PVT persists in a single patient (1.1%).

Conclusion
A proactive, pre-emptive strategy prevents PVT-related morbidity, achieving excellent long-term patient and graft outcomes.