A technically difficult liver transplant was performed in a 68-yr-old male with Alveolar Echinococcosis causing end-stage liver disease. The pathology was extensive and included hepatic artery thrombosis, Budd-Chiari syndrome, and right hemidiaphragm invasion necessitating resection of this portion of diaphragm and direct donor cava anastomosis to the right atrium. The patient is now 21 months since transplant disease free with normal liver function.