*Purpose: In October 2015, the UNOS policy for hepatocellular carcinoma (HCC) exception scores was changed to modify the maximum exception value and prolong the time until the score was increased (6-month waiting time). This increases the need to bridge HCC liver candidates with locoregional therapy (LRT). Around the same time, utilization of Y-90 radiation microspheres (Y-90) has become more popular but limited data exists to support its use for waiting list survival and successful bridge to transplant.

*Methods: Using OPTN data, all HCC liver transplant candidates listed and who received an exception after the policy (Oct 5, 2015) were included in the study. Recipient, OPO, Region, and Center demographics were analyzed for univariate and multivariate risk factors for waiting list mortality and successful bridging to transplant. Univariate analysis was performed using chi square, t-test, and Kaplan Meir curves and Cox Proportional Hazard models were used for multivariate analysis.

*Results: During the study period (Oct 5, 2015 to Jun 10, 2019), 1,538 (17.0%) were treated with Y-90 either before or during listing of a total of 9,031 candidates. 15.3% of candidates treated with Y-90 died during the observation period compared to 16.26% (p=ns) who received other LRT’s. Y-90 candidates were similar with respect to age, MELD, gender, blood type, but were more likely to have private insurance, higher functional status, less comorbidities, and had a shorter waiting time. Having received Y-90 while on the transplant waiting list was not an independent predictor of mortality (HR 1.10, p=0.28). A lower proportion of candidates receiving Y-90 (46.8%; p=0.007) were bridged to transplant compared to TACE (53.4%, n=3,381), external radiation (51.1%, n=143), or thermal ablation (50.4%, n=1,783). When controlling for confounding variables with multivariate analysis, Y-90 did not significantly impact the likelihood for transplant (HR 0.71, CI 0.42-1.22, p=0.21).

*Conclusions: With changes in UNOS policy that have capped MELD exception scores and mandated a waiting time until receiving exception points, more effective LRT is needed to bridge HCC candidates to liver transplant. While Y-90 utilization is increasing, it is associated with a decreased likelihood to receive a liver transplant but is not an independent risk factor for receiving a transplant or waiting list mortality.

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