*Purpose: VCA transplantation has grown and changed, encountering challenges such as scarce funding sources and the COVID-19 pandemic.

*Methods: The OPTN cohort includes 105 candidates listed and 62 recipients transplanted 7/4/14-10/31/21.

*Results: VCA candidates included 47 uterus, 26 upper limb (UL, 14 bilateral, 12 unilateral), 1 UL/face, 12 face, 1 scalp, 2 face/scalp, 1 trachea, 12 abdominal wall (AW), and 3 penis candidates. Waiting list additions increased in 2016 after uterus transplants began in the US. Head and neck and UL additions held relatively steady through 2019. The COVID-19 pandemic caused a decrease in VCA waiting list additions in 2020 – 1 AW, 1 uterus, and two UL candidates. In the first 10 months of 2021, 5 VCA candidates were added – 2 AW and 3 uterus candidates. In April 2020, 11 of 23 VCA candidates were inactive; on 10/31/2021, 8 of 21 were inactive.

62 candidates received 64 transplants (including 1 uterus re-transplant and 1 face/UL transplant). Others refused transplant (n=7), became ineligible (n=4), could not be contacted (n=2), condition improved (n=1), were too sick (n=2), died (n=3), or were removed for other reasons (n=2). Median time on the waiting list for recipients was 217 days (IQR: 76.0-404.25 days).

VCA transplants in the U.S. 7/3/14-10/31/21 include 14 UL (9 bilateral; 5 unilateral), 9 face, 1 UL/face, 1 scalp, 1 trachea, 2 AW, 2 penis, and 33 uterus (12 deceased donor; 21 living donor). In 2016, VCA shifted from mostly UL and face to a larger proportion of uterus transplants. UL and face transplants decreased in 2017, then increased and held steady through 2019. VCA transplants decreased in 2020 with the COVID-19 crisis and included 2 uterus transplants, the first U.S. face re-transplant, and the first successful UL/face transplant in the U.S. In the first 10 months of 2021, 2 living donor uterus, 1 bilateral UL, and the first trachea transplant in the US occurred. Out of 62 recipients, 21 were funded by the hospital, 15 by donations, 7 by Medicare/Medicaid, 1 by Dept of Veterans Affairs, 3 by private insurance, and 2 by recipient.

*Conclusions: VCA transplantation continues to faces challenges such as the COVID-19 pandemic and chronic issues such as funding sources, but has shown signs of resilience in 2021.

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