Atherosclerosis in renal allograft recipients necessitated modification of vascular anastomoses in 62 per cent of patients older than forty years in contrast with 10 per cent in younger patients. Three forms of vascular disease occurred: atherosclerotic occlusion, tortuosity of vessels, and disruption of plaques by vascular clamps. Successful modifications of the procedure and avoidance of ischemic graft injury are described including relocation of the transplanted ureter.