Adequate portal inflow is mandatory to ensure graft and patient survival after liver transplantation. Non-tumoral portal vein thrombosis (PVT) is present at liver transplantation in 5% to 26% of cirrhotic patients, and the prevalence of complex PVT (grade 4 Yerdel, and grade 3,4 Jamieson and Charco) has been reported in 0% to 2.2%. Dealing with complex PVT is a challenge especially when it is a surprise at the time of LT, and even more so in the LDLT setting, where short lengths of graft vessels make inflow reconstruction even more difficult in recipients with extensive PVT. Thus, most guidelines still contraindicate LT alone in patients with complex PVT. Early recognition and delineation of the grade and extent of PVT, careful planning of the proposed method of portal inflow to the graft at LT beforehand, and sometimes pre-LT recanalization of the portal vein to ensure a physiological porto-portal anastomosis during LT are all very important. In complex PVT, portal reconstruction can be considered physiological when the splanchnic blood is somehow redirected to the graft, thus resolving the pre-existing PHT. In the presence of significant concomitant shunts like a lienorenal shunt, a renoportal anastomoses may be preferred. Similarly, a large gastric vein or pericholedochal varix may be used for physiological inflow. If no shunts are present, a renoportal anastomoses, cavoportal hemitransposition, or portal vein arterialisation may be used as salvage non-physiological inflow procedures. Multivisceral transplant is the only other option for physiological reconstruction in these cases, but good results have not been reproduced by too many centers. In short, in complex PVT, the surgical strategy needs to be tailored to an individual patient in order to provide portal inflow to the graft together with control of prehepatic portal hypertension whenever feasible. Postoperatively, good flows need to be ensured on USG Doppler, and low molecular weight heparin may be used during the initial 2 weeks, followed by aspirin for 3 months. More importantly, it is essential to rule out and manage initial persistent portal hypertension by frequent upper GI endoscopies and watch for ascites, when non porto-porto inflow techniques have been used during LT.