Despite considerable progress in understanding the mechanisms of discordant xenograft rejection, and overcoming hyperacute rejection through targeting of complement or antibody, vascularized xenografts are typically rejected within days. Here, Fritz Bach and colleagues discuss the importance of endothelial cell activation, platelet aggregation and other aspects of thrombosis, as well as the contribution of host natural killer cell and monocyte activation in overcoming this next barrier to prolonged xenograft survival.