A Pragmatic Approach to Normothermic Regional Perfusion and Machine Perfusion in Donation After Circulatory Death Liver Transplantation

: Controlled donation after circulatory death (DCD) liver transplantation in Italy is uniquely challenged by a legally mandated 20 minute no-touch period after circulatory arrest, prolonging warm ischemia before intervention. In this setting, graft viability depends not only on donor selection but also on the rapid, effective establishment of normothermic regional perfusion (NRP). We describe a standardized technical approach to rapid NRP initiation and intraoperative graft triage in Maastricht category III DCD donation. After the no-touch period, percutaneous femoral cannulation is initiated while laparotomy and sternotomy are performed in parallel. In cases of failed cannulation or inadequate perfusion, a predefined surgical rescue strategy is applied. Graft selection is guided by a structured five-parameter assessment: when all criteria are met, grafts proceed to transplantation after hypothermic perfusion (HOPE/D-HOPE); when partially met, ex situ normothermic machine perfusion (NMP) is performed with transplantation only if functional recovery is achieved; when not met, grafts are discarded. Between November 2018 and December 2025, 38 donors were evaluated, and 33 grafts (87%) were transplanted. All transplanted grafts achieved 100% graft and patient survival. This standardized, reproducible approach may improve graft utilization and optimize integration of NRP and machine perfusion in settings with prolonged legally mandated no-touch intervals.