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Abstract : BACKGROUND: Traditionally, deceased donor liver grafts receive dual perfusion through the portal vein and the hepatic artery(HA) either in-situ or on the back-table. Hepatic artery perfusion is avoided in live donor liver grafts for fear of damage to the intima and consequent risk of hepatic artery thrombosis(HAT). However, biliary vasculature is predominantly derived from the HA. We hypothesized that antegrade perfusion of the HA in addition to the portal vein on the back table could reduce the incidence of post-operative biliary complications. METHODS: Consecutive adult patients undergoing live donor liver transplants (LDLT) were randomized after donor hepatectomy to receive graft perfusion of HTK (Histidine-tryptophan-ketoglutarate) solution either via both the hepatic artery and portal vein (dual perfusion group,n=62) or only through the portal vein (standard perfusion group,n=62). The primary endpoints were the occurrence of biliary complications (biliary leak/stricture). Secondary endpoints included hepatic artery thrombosis and patient survival. RESULTS: The incidence of biliary stricture was significantly lower in the dual perfusion group 6.5% vs.19.4%[OR 0.29, 95%CI(0.09-0.95);P=0.04]. There was no significant reduction in the incidence of HAT, bile leak or hospital stay between the two groups. Three year patient and graft survival was significantly higher among patients who received dual perfusion compared to standard perfusion[P=0.004, P=0.003]. On multivariate analysis non perfusion of the hepatic artery and preceding bile leak were found to be risk factors for the development of biliary stricture(P=0.04 & P<0.001). CONCLUSIONS: Dual perfusion of live donor liver grafts through both hepatic artery and portal vein on the back-table may protect against the development of biliary stricture. This could translate to improved patient survival in the short-term. This article is protected by copyright. All rights reserved.