Potential conflict of interest: Nothing to report. See Article on Page 457 Living donor liver transplantation (LDLT) outcomes have continued to improve over the last 3 decades and, in many centers, are equivalent to those with deceased donor transplant. Use of a partial graft from a living donor presents unique challenges in performing vascular and biliary anastomoses due to smaller and shorter structures. Descriptions of methods to reconstruct vessels in LDLT are abundant,1 with little doubt that a learning curve does exist. In a report from the Adult‐to‐Adult Living Donor Liver Transplantation Cohort Study (A2ALL), outcomes improved after 20 cases5 with a decrease in vascular and biliary complications. Vascular complications in liver transplant, especially when early (within the first month) are often associated with graft loss. United Network for Organ Sharing recognizes this with its policy that arterial thrombosis within the first 14 days after transplant allows higher priority on the deceased donor waiting list for retransplant. Previous reports have described vascular complication rates as high as 24%, although most experienced centers have vascular complication rates of approximately 5%. For instance, the A2ALL group reported an arterial complication rate of 5.1% after participating centers gained experience, with a portal vein complication rate of 1.8%.5 Minimizing vascular complications involves attention to detail at all phases of the liver transplant procedure—preoperative, intraoperative, and postoperative. There are some well‐accepted standards, but many of the specifics of management differ among centers. Some areas of debate include appropriate selection of donors. For example, should donors with potential multiple arteries or complex portal or hepatic vein anatomy even be considered? Intraoperative management questions that are still unsettled include techniques of arterial anastomosis including selection of the best inflow vessel, use of a microscope or higher loupe magnification, interrupted versus running suture, need for reconstruction of accessory hepatic veins, and use of an implantable Doppler for monitoring of arterial patency. Postoperatively, debate exists as to the frequency of assessment of vessels with ultrasound and need for anticoagulation. Unfortunately, randomized trials to answer these questions are difficult because of the complex nature of the procedure and the need for a large cohort to demonstrate any differences. Thus, the field has relied primarily on case series. Rather et al.6 in this issue of Liver Transplantation report a remarkable series of 1132 living donor transplants, both pediatric and adults, in which they review changes in outcomes of vascular complications over 2 time periods (391 patients in an early cohort versus 741 in a more recent cohort) all performed by the same surgeon. The report describes key complications with an arterial thrombosis rate of 0.5% in the more recent cohort versus 2.2% in the earlier experience. The portal vein thrombosis rate was 1.4% in adults and 7.3% in pediatric recipients in the newer cohort, which did not differ from the earlier cohort. There was also a decrease in reconstructed middle hepatic vein thrombosis rates when the middle hepatic vein was used. The recipient characteristics changed only in terms of higher Model for End‐Stage Liver Disease scores in the more recent recipients with over 75% of grafts being conventional right lobes. Other than the vast experience accumulated by the single surgeon, what other factors contributed to these exceptional results? The authors outline their protocol for monitoring of the graft, with twice daily Doppler ultrasounds in the first 5 postoperative days, followed by daily ultrasounds until day 7. Although frequent monitoring will not prevent thrombosis, it facilitates prompt intervention. With this approach, 3/14 (21.4%) grafts with arterial thromboses were salvaged with reoperation. Anticoagulation was used routinely in pediatric patients, but its use in adult patients in the newer cohort had been discontinued because of the occurrence of intracerebral bleeds in the earlier cohort. Absence of anticoagulation did not seem to increase thrombosis rates. The authors also stress the importance of accessory hepatic vein reanastomoses to decrease graft swelling with its impact on inflow, which may contribute to the risk of thrombosis. Matching these results for most centers will be challenging because it will require similar surgical experience. Additional strategies may involve other disciplines, such as plastic surgeons skilled in microvascular anastomoses. Adequate time to properly perform this operation is also important. The average operating time in the newer cohort in this series was 11.5 hours, certainly much longer than most deceased donor operations. Careful attention to hepatic vein reconstruction, especially of smaller accessory veins, is also becoming more accepted to reduce graft swelling. The utility of frequent ultrasounds needs to be confirmed because only a small number of grafts were salvaged. Implantable Doppler placed on the hepatic artery could be an alternative for monitoring in the first 5 days, with ultrasounds being obtained when there is a change in Doppler signal. Although a thrombosis rate of 0 will never be achieved, all centers are now challenged to match the results reported by Rather et al. And with a procedure that is so technically demanding, practice makes perfect—or at least close to it.