BACKGROUND: Portal vein thrombosis in liver transplant recipients presents a significant challenge, with potential implications for posttransplant biliary complications. This study investigated the relationship between portal vein thrombosis and posttransplant biliary complications, aiming to identify risk factors and establish a stratification framework.

METHODS: We conducted a single-center retrospective study of 914 adult liver transplant recipients from 2016 to 2023. Portal vein thrombosis was classified using the Yerdel system, and multivariate logistic regression analysis was conducted to identify the predictors for posttransplant biliary complications.

RESULTS: Portal vein thrombosis was present in 109 (11.9%) recipients, with grade I in 78 (71.6%), grade II in 25 (22.9%), and grade III in 6 (5.6%) cases. Posttransplant biliary complication rates increased with portal vein thrombosis severity (grade I: 15.4%, grade II: 52.0%, grade III: 100%). Multivariate analysis identified portal vein thrombosis (odds ratio, 2.68; P < .001), donation after circulatory death (odds ratio, 1.50; P = .04), and advanced donor age (odds ratio, 1.01; P = .04) as independent risk factors for posttransplant biliary complications. Donation after circulatory death donors showed consistently greater posttransplant biliary complication rates across all age groups, whereas donation after brain death donors demonstrated increased risk with age >40 years. Although graft survival was comparable between groups, portal vein thrombosis recipients required more frequent endoscopic retrograde cholangiopancreatography interventions within the first post-transplant year (38.5% vs 28.2%, P = .03).

CONCLUSION: Portal vein thrombosis significantly increases posttransplant biliary complication risk, particularly with greater Yerdel grades and when combined with donation after circulatory death grafts or advanced donor age. Although long-term outcomes remain similar, portal vein thrombosis recipients require more frequent interventions. Preoperative risk stratification on the basis of these factors may guide intraoperative management and post-transplant surveillance, potentially improving outcomes in this challenging population.