Primary graft dysfunction is a syndrome of acute lung injury following lung transplantation, defined by hypoxemia and pulmonary edema on imaging. The ISHLT classifies PGD by PaO2/FiO2 ratio and chest X-ray findings. PGD is largely driven by ischemia-reperfusion injury and inflammatory processes. Risk factors span donor, recipient, and intraoperative variables, including single-lung transplant, high reperfusion FiO2, and intraoperative transfusion. Management parallels ARDS strategies: lung-protective ventilation, fluid restriction, and in severe cases, ECMO support. Prevention focuses on optimal donor selection, improved preservation techniques, and meticulous intraoperative management including controlled reperfusion and early escalation to extracorporeal support.