Orthotopic liver transplantation (OLT) has evolved over the last forty years from an experimental endeavor to standard of care therapy for many patients with end stage hepatic disease.  Many technical advances have contributed to the current success of OLT, but surgical complications, especially involving the biliary reconstruction, remain a morbid problem.  Biliary complications after OLT include leaks and strictures.  Strictures may be anastomotic or intrahepatic and diffuse, as seen in cases of hepatic artery thrombosis.
Current efforts to expand the limited donor pool include the use of non-heart beating donors.  The organ procurement process in these donors entails an increased period of warm ischemia and results with non-heart beating donor grafts have been mixed.  It is now appreciated that there is an increased incidence of subsequent diffuse biliary stricturing or “ischemic cholangiopathy” in recipients of these organs.  Animal models of this phenomenon and potential therapeutic strategies targeted at ischemic cholangiopathy are being developed with potential applicability to non-heart beating donation and will be the focus of this review.