Abstract-Despite the development of effective immunosuppressive therapy, transplant graft arterial disease (GAD) remains the major limitation to long-term graft survival. Multiple immune and nonimmune risk factors contribute to this vasculopathic intimal hyperplastic process. Thus, initial interplay between host inflammatory cells and donor endothelial cells triggers alloimmune responses, whereas alloantigen-independent factors such as prolonged ischemia, surgical manipulation, ischemia-reperfusion injury, and hyperlipidemia enhance the antigen-dependent events. Intrinsic to all stages of this process are chemokines, a family of 8-to 10-kDa proteins mediating directional migration of immune cells to sites of inflammation and injury. Beyond their role in immune-cell chemotaxis, chemokines also contribute to cellular activation, vascular remodeling, and angiogenesis. Expression of chemokines and their cognate receptors in allografts correlates with acute organ rejection, as well as GAD. Moreover, chemokine or chemokine receptor blockade prolongs graft survival and attenuates GAD in experimental models. Further studies will likely confirm a substantial utility for antichemokine therapy in human organ transplantation. Key Words: atherosclerosis pathophysiology Ⅲ other arteriosclerosis Ⅲ transplantation Ⅲ vascular biology, smooth muscle proliferation and differentiation G raft arterial disease (GAD), also termed allograft arteriopathy, graft vasculopathy, or transplant-associated arteriosclerosis is a vascular intimal proliferative process leading to ischemia and the progressive deterioration of allograft function. GAD is the major limitation to long-term graft and recipient survival after heart transplantation. 1 One-year, 3-year, 5-year, and 10-year survival afte adult heart transplantation is 92%, 80%, 73%, and 49%, respectively, 2 with the majority of mortality attributable to GAD. Intimal thickening, medial attenuation, adventitial fibrosis, and vasoconstriction characterize GAD lesions. 3 These can develop and progress at any time and at variable rates; significant vasculopathy can develop as early as 6 to 12 months posttransplant. Intravascular ultrasound (IVUS) demonstrates GAD in 75% of patients at 3 years after transplantation. 4 Clinical diagnosis of GAD is limited by the lack of ischemic symptoms in the largely denervated allograft, by the relative insensitivity of coronary angiography-which frequently underestimates the extent and severity of diffuse disease-and by the extensive involvement of small intramyocardial vessels. For most cases, retransplantation is the only effective therapy for established GAD, because disease diffuseness usually precludes angioplasty, endarterectomy, or bypass grafting.The mechanisms underlying GAD include antibodymediated and cell-mediated inflammation, followed by tissue remodeling. T cells, B cells, macrophages, dendritic cells, platelets, natural killer (NK) cells, or neutrophils, and vascular cells such as endothelial cells (ECs) and smooth muscle cells (SMCs) all co...