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Actually the biggest hurdle to this is simply the sheer amount of level design work required. Vaal side areas are not something that we can easily enable for any area or map - they require hand-crafted integration for every variant of the map/area by a level designer.
This is mostly a relic of the past (Sacrifice of the Vaal was released over 5 and a half years ago, after all); we don't generally create content that requires so much custom work per area any more. But back then, we only had 3 Acts of content, so it wasn't such a big deal at the time.
To illustrate, when a Vaal side area spawns, we don't just swap in the entrance tile somewhere - we create entirely new corridors, rooms, valleys, paths, bridges, etc. leading up to the entrance. It can actually make the area noticeably bigger, and usually means more monsters/chests/etc. to fill the extra space.
The type of entrance also affects which Vaal side you get. So a sewer grating entrance always...
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