Endovascular management of extrahepatic portal vein obstruction (EHPVO): expanding beyond surgical shunts.

Extrahepatic portal vein obstruction (EHPVO) is a major cause of noncirrhotic portal hypertension, particularly in children and young adults. Traditionally, definitive management relied on surgical shunts such as proximal splenorenal shunt and meso-Rex bypass; however, extensive porto-mesenteric thrombosis, unfavorable anatomy, perioperative morbidity, and limited surgical expertise may restrict surgical feasibility in many patients. Over the last decade, advances in interventional radiology have substantially expanded therapeutic options beyond surgery. Portal vein recanalization (PVR) is increasingly considered a physiological endovascular treatment strategy in anatomically suitable patients because it restores hepatopetal portal flow while preserving native hepatic perfusion. In patients with diffuse intrahepatic involvement, persistent portal hypertension, or inadequate portal inflow, adjunctive transjugular intrahepatic portosystemic shunt (TIPS) may improve decompression and long-term patency. Transjugular extrahepatic portosystemic shunt (TEPS) serves as an advanced salvage option in complex anatomy unsuitable for conventional TIPS, while partial splenic embolization and variceal embolization complement management of hypersplenism and refractory variceal bleeding. This review provides an overview of endovascular interventions in EHPVO, highlighting the underlying rationale, patient selection, techniques, outcomes, and complications.