A 2-year-old Chinese boy with progressive familial intrahepatic cholestasis type II-related end-stage liver disease underwent living donor liver transplantation (LDLT) using a left lateral segment graft from his mother. Preoperative computed tomography angiography showed that the hepatic artery, inferior vena cava, and portal vein were patent. The left portal vein of the graft was connected to the recipient's right anterior portal vein. The left hepatic vein of the graft was connected to the recipient's hepatic veins with triple venoplasty. The left hepatic artery of the graft was connected to the recipient's right hepatic artery. The left hepatic duct of the graft was connected to the recipient's common hepatic duct with a microsurgical technique.After the operation, the infant underwent reworking of the hepatic artery anastomosis twice because of early hepatic artery thrombosis. He also underwent revision of the biliary reconstruction to Roux-en-Y hepaticojejunostomy because of biliary anastomotic stricture. At 18 months post-transplant, there was poor visualization of the intrahepatic portal vein, but there was hepatofugal flow inside the left portal vein during Doppler ultrasound follow-up studies. Splenomegaly and minimal ascites were also noted by ultrasound. The computed tomography angiography study showed mild intrahepatic bile duct dilatation, marked splenomegaly, and occlusion of the transverse portion of the portal vein with collateral vessels also noted. The patient was subsequently referred for a possible interventional radiological procedure as initial management for the occluded portal vein.The patient underwent vascular catheter intervention under general anesthesia. The percutaneous transsplenic approach was performed to puncture the splenic vein with a 21-gauge Chiba needle (Cook, Bloomington, IN) under ultrasonographic and fluoroscopic guidance. The needle was changed to a 4-French coaxial dilator and a 7-French sheath (Terumo, Tokyo, Japan) over a 0.035-inch angled hydrophilic guide wire (Terumo) after confirmation that the needle was in the splenic vein. Direct main portal venography and the pressure gradient across the stenosis were then obtained. Portography showed total occlusion of the portal vein at its umbilical portion (Fig. 1). The coronary vein was prominent, and gastroesophageal varices were also noted. The extrahepatic portal pressure was 18 mm Hg, and the intrahepatic portal pressure was 18 mm Hg. Hence, there was no pressure gradient across the area of stenosis. A 0.035-inch guide wire and a 4-French J curve catheter (Terumo) were used to traverse the area of portal vein stenosis (Fig. 2). A wall stent (9.0 mm ϫ 5.0 cm; Boston Scientific, Natick, MA) was placed to bypass the area of stenosis from the umbilical portion up to the visualized segment 3 portal vein. A second similarly sized wall stent was placed from the mid portion of the native main portal vein to the splenic vein.Balloon angioplasty (6.0-40 mm, 80 cm; Wanda, BosAbbreviation: LDLT, living donor liver transplantati...