Introduction: Hepatic venous outflow obstruction (HVOO) is a serious vascular complication that entails a high risk of early graft loss. Our aim is to present a novel graft salvaging surgical technique.
Methods: A retrospective analysis of liver transplant (LT) recipients with early-onset HVOO (1 month postLT) between 2013-2023.  
Results: Out of 157 LTs, four patients (2,5%) presented early-onset HVOO and all required surgical treatment. In patient 1 and 2 outflow was reestablished by reconstructing the end-to-side piggy-pack anastomosis under hepatic exclusion. 
Patient 3 received a combined liver-kidney transplant with a side-to-side piggy-back anastomosis and presented with refractory ascites on day 4. Hepatic venography confirmed a drainage issue secondary to excessive sectioning of the suprahepatic stump, requiring surgery 8 days postransplant. Under hepatic exclusion a donor-harvested femoral vein was employed to elongate the short suprahepatic stump and increase surface area of drainage.   
Patient 4 received a reduced left liver graft with an end-to-side piggy-pack anastomosis and presented with refractory ascites and pleural effusion on day 12. Hepatic venography confirmed kinking of the middle and left hepatic veins, which precluded venoplasty and stenting, warranting surgery 16 days postransplant. Under hepatic exclusion a donor-harvested femoral vein was employed to elongate the suprahepatic stump and convert the end-to-side anastomosis into a side-to-side anastomosis. The patient required retransplantation after 10 months due to refractory rejection. None of the patients required venovenous bypassing. 
Conclusion: Employing a venous graft to elongate the suprahepatic stump, is a feasible, effective and ingenious surgical alternative to treat HVOO.