The contribution of microcirculatory failure to ischemia/reperfusion injury in isolated perfused rat livers was investigated using intravital epifluorescence videomicroscopy. The degree of microvascular shut-down during reperfusion was modulated by the reperfusion conditions: flow-controlled (10 ml/min), in which microcirculatory failure is minimized by maintenance of constant flow through the liver, and pressure-controlled, in which microvascular shut-down is allowed to occur. Livers underwent 60 min of ischemia, 90 min of ischemia, or no ischemia (control). Perfused sinusoids and dead hepatocytes were quantified in 10 standardized microscopic fields (9000 microns2) per liver during off-line video playback. With flow-controlled reperfusion, microvascular (sinusoid) shut-down was largely avoided; a maximum of 21% of the sinusoids failed to conduct flow. Pressure-controlled reperfusion, however, resulted in early and severe shut-down. A significant decrease of approximately 20-30% was found after 60 min of ischemia and 30 min of reperfusion, while, after 90-min ischemia and 90-min reperfusion, 90% of the sinusoids failed to conduct flow. The appearance of dead hepatocytes correlated well with the number of perfused sinusoids (r = -0.78 for flow controlled, r = -0.97 for pressure-controlled). Only an occasional dead hepatocyte was observed with control perfusion, while up to 50% stained with propidium iodide following 90-min ischemia and 90-min reperfusion under pressure-controlled conditions. These results indicate that loss of sinusoidal flow can be ameliorated by flow-controlled reperfusion; moreover, hepatocyte necrosis during reperfusion is highly dependent upon the integrity of the microcirculation.