Sustained effectiveness of balloon-occluded retrograde transvenous obliteration for portopulmonary hypertension after liver transplantation: a 5-year follow-up case report.

Portopulmonary hypertension (POPH), a subtype of pulmonary arterial hypertension (PAH), develops with portal hypertension and may persist after liver transplantation. While there have been successes using balloon-occluded retrograde transvenous obliteration (BRTO) for POPH, no reports exist on long-term follow-up. A 60-year-old man with hepatitis C cirrhosis developed POPH. At the time POPH was diagnosed, the mean pulmonary artery pressure (mPAP) was 31 mmHg. After medical management, mPAP improved to 20 mmHg, and he underwent living-donor liver transplantation. Three years post-transplant, he presented with severe dyspnea and elevated mPAP of 67 mmHg. Despite pharmacological treatment for PAH, his symptoms and pulmonary pressures remained uncontrolled. After transplantation, the pre-existing splenorenal shunt expanded, suggesting that increased shunt blood flow contributed to worsening POPH. BRTO was performed after confirming that shunt occlusion did not elevate portal pressure. Post-procedure, his pulmonary pressures improved (mPAP, 25 mmHg), and symptoms resolved. Over 5 years, no recurrence of POPH, portal hypertension, or liver dysfunction occurred. This case demonstrates the long-term effectiveness of BRTO in treating POPH exacerbation post-liver transplantation. In cases of POPH following liver transplantation, portosystemic shunt occlusion via BRTO may be an effective strategy to improve POPH.