Background: Multiple orthotopic liver transplantations (OLTx), although relatively uncommon, are the only known therapy for repeated graft failure. Moreover, re-transplantation (re-OLTx) of more than 2 grafts is sparsely reported thus far.
Case Report: We describe here 2 cases of patients who fulfilled the criteria for undergoing more than 2 OLTx. Each patient received 3 grafts in total. The primary early indication for the first re-OLTx in both cases was hepatic artery thrombosis (HAT). Prior to the second re-OLTx, both patients were in poor general condition. In 1 case, the second graft failed due to the recurrence of primary sclerosing cholangitis; the patient was re-transplanted electively 69 months after the primary re-OLTx. In the other case, the patient required a non-elective second re-OLTx within 1 month after the first re-OLTx due to primary graft failure. In both patients, the second and the third re-OLTs were performed using a veno-venous bypass with hepaticojejunostomy on an already existing Roux-en-Y loop. While 1 patient died postoperatively due to multi-organ failure, the other is alive with good synthetic liver function at 60 months after the last transplantation. The overall mortality rate of this procedure was thus 50%.
Conclusions: Although repeated OLT of more than 2 grafts is technically feasible and in selected patients can be a life-saving procedure, it is rarely performed. In our limited experience, it is burdened with relatively high mortality and morbidity, unspecified indications regarding patient selection, and competition between patients awaiting liver transplantation.

Keywords: hepatic artery thrombosis, re-transplantation, primary nonfunction