In their letter, Dr. Kayaalp et al. take issue with the management described in a case report of hydatid disease that resulted in inferior vena cava (IVC) and hepatic vein obstruction and stenosis with subsequent portal venous hypertension. 1 They state that they do not believe the patients' symptoms can be attributed to portal hypertension and believe that lifelong anticoagulation is required for a Gortex graft placed in the retrohepatic, suprarenal position. They also state that they believe the cyst must have had a low intracystic pressure since it was old and calcified. As a general comment, we would state that the requirement for resection of the IVC for hydatid disease should be incredibly rare, hence our belief that the case report might be of interest.At the operative procedure, it was clear that there was a tremendous inflammatory response to the cyst that might explain the symptoms. In our case report, we did not state that the patient had any symptoms related to portal hypertension, only symptoms of pain and shortness of breath, which we would assume most people know are not symptoms of portal hypertension. While we did not measure intracystic pressures, on opening the cyst, the contents appeared to be under relatively high pressure. We, in fact, initially believed that simply reducing the pressure by decompressing what appeared to be a high-pressure hydatid cyst might relieve the hepatic venous outflow obstruction and relieve the portal venous hypertension. When this did not occur, we believed that shunting of total IVC flow through the large inferior hepatic vein across the liver and out a stenotic left hepatic vein that was unable to accommodate the high flow of combined portal and caval flows was the cause of the portal venous hypertension. Resecting the cyst/liver effectively removed the source of inflammation, interrupted the collaterals through the liver, and replaced the completely occluded IVC. It allowed reduction of flow through the only remaining hepatic vein and relieved the portal hypertension. We felt that leaving a correctable form of portal hypertension uncorrected at operation would be inappropriate. We have reported previously on a moderately large series of combined liver and IVC resections for malignancy. 2 Current combined liver and IVC resections, including malignant and nonmalignant cases, at our institution now number over 30 cases. All grafts are patent with follow-up from 3 months to 8 years, and no patients with a Gortex ring graft have been placed on any anticoagulation after their procedure apart from a daily baby aspirin. There is no evidence that lifelong anticoagulation is required for Gortex grafts placed in the retrohepatic suprarenal position. After the surgery, the patient was symptom-free for the first time in over 3 years, has returned to work for the first time in 2 years and has a patent graft on no anticoagulation. Since both symptoms and portal hypertension are gone and the patient is not on anticoagulation, we feel we made an appropriate choice. References 1....