Donation after circulatory death (DCD) liver transplantation is emerging as a critical solution to the global shortage of liver grafts, particularly for complex recipients with multiple comorbidities. Although overall survival rates for DCD liver transplants are improving, concerns persist regarding short- and long-term outcomes, including delayed graft function (DGF) and primary non-function (PNF). This chapter delves into the multifaceted challenges of utilizing DCD livers in complex recipients, highlighting the importance of donor-recipient matching, risk stratification models, and advanced organ preservation techniques. Factors such as warm ischemia time (WIT), donor quality, and comorbid conditions like cardiovascular disease and diabetes significantly impact transplantation outcomes. New methodologies, including normothermic machine perfusion (NMP) and normothermic regional perfusion (NRP), are pivotal in enhancing graft viability and mitigating ischemic injury. Furthermore, ethical considerations regarding organ allocation and recipient suitability are explored, emphasizing the need for continued refinement of strategies to improve transplantation outcomes for high-risk patients. By synergizing innovative preservation techniques with multidisciplinary assessment, this chapter aims to provide a comprehensive understanding of optimizing DCD liver transplantation in complex clinical scenarios.