This article describes experience with preservation of portal and caval flow during orthotopic liver transplantation (OLT) for fulminant or subfulminant hepatic failure (FSHF) as an alternative to venous bypass. As a modification of the standard procedure, hepatectomy and graft implantation were performed with preservation or caval patency in combination with a temporary portocaval shunt. From July 1991 to March 1994, 25 consecutive patients with FSHF underwent OLT with preservation of portal and caval flow. All patients had severe confusion (n = 9) or coma (n = 16) with a mean(s.d.) clotting factor V of 13(5) per cent and a mean(s.d.) serum bilirubin level of 408(151) μmol/l. During the anhepatic phase, haemodynamic data showed a preservation of cardiac filling pressure, mean arterial pressure, and renal perfusion pressure, while the mean(s.d.) urine flow was maintained at 182(120) ml/h. Venous bypass was not required. There were three (12 per cent) deaths after the operation, and all survivors made a full neurological recovery. Normal postoperative creatinine values allowed the early use of baseline immunosuppression. The authors conclude that, in patients with FSHF, successful liver transplantation can be achieved with this technical procedure.