Iliac Artery Conduits in Primary Liver Transplantation: Long‐Term Outcomes and Graft Survival

BACKGROUND: Arterial conduits are effective when normal graft arterialization is not feasible in liver transplantation (LT), but long-term outcomes for both patient and graft survival are variable across studies. Most studies combine primary and re-transplant recipients, are limited by small sample sizes, and do not include propensity-matched controls. METHODS: We included adults undergoing primary LT at a quaternary academic center between 1/1998 and 8/2025 with iliac artery conduits. Conduit patients were propensity matched using a full matching approach. Kaplan-Meier and Cox regression evaluated the effect of arterial conduits on post-transplant patient and graft survival and hepatic artery thrombosis (HAT). RESULTS: Compared with controls (n = 2695), LT recipients with iliac artery conduits (n = 100) had similar patient and graft survival at 20 years post-transplant. However, conduit recipients had a greater risk of early (HR 6.07, 95% CI 2.09-17.57, p = 0.001) and late HAT (HR 4.34, 95% CI 1.45-13.05, p = 0.009). Even following re-transplantation for HAT, iliac artery conduit recipients had decreased 5-year survival compared with controls. Conduit length, placement, and reasons for graft use were not predictive of overall HAT incidence, death, or graft failure. CONCLUSION: Compared with matched controls, patients with iliac artery conduits have comparable 20-year graft and patient survival. Although conduit use may not increase mortality risk, it may identify patients with vascular susceptibility, who face high risk of HAT in both the early post-transplant period and across long-term follow-up. For patients with iliac artery conduits, long-term survival may be optimized through routine, extended follow-up with vascular imaging to detect and manage late HAT.