Anatomical risk stratification for major portal vein complications in dual portal vein living donor liver transplantation: a retrospective cohort study.

Purpose: Right lobe living donor liver transplantation (LDLT) with dual portal veins (PVs) remains technically challenging. This study aimed to identify independent risk factors for PV complications. Methods: We retrospectively analyzed 111 recipients of dual PV LDLT between 2011 and 2020. Recipient characteristics, anatomical geometry, and surgical factors were evaluated. Outcomes were overall PV complications and major PV complications (Clavien-Dindo grade ≥III). Logistic regression was performed. Results: PV complications developed in 41 patients (36.9%), including 16 major events (14.4%). Univariate analysis revealed associations with right posterior PV (RPPV) diameter, axial angle, and coronal angle. On multivariate analysis, larger RPPV diameter (odds ratio [OR], 1.79; P = 0.041) and wider axial angle (OR, 1.08; P = 0.015) were independent predictors of major PV complications. Reconstruction method was not significant. Patients with overall major Clavien-Dindo grade ≥III complications had inferior 100-month survival (80% Conclusion: In dual PV LDLT, anatomical geometry-specifically RPPV diameter and axial angle-independently predicts major PV complications, whereas surgical technique does not. Preoperative 3-dimensional imaging and anatomical risk stratification should inform donor selection and surgical planning.