Despite early identification and aggressive modification of atherosclerotic risk factors, many patients still require surgical revascularisation for established atherosclerotic vascular disease. However, bypass surgery is hampered by a high incidence of vein graft failure. New strategies are being introduced to improve these results, with early data suggesting that improved patency rates are possible. These vary from the use of adjuvant pharmacological agents and local gene transfer strategies to the modification of vein harvesting techniques in order to reduce vascular damage to all layers of the graft. Advances in vascular biology have resulted in new insights into the role of the endothelium and adventitia in vein graft remodelling. Although recent pharmacological adjuvant therapy and molecular techniques have been described that may be used to reduce the incidence of vein graft occlusion a more desirable approach for improved graft patency rates may be achieved simply by using atraumatic surgical techniques aimed at minimising vascular damage during vessel harvesting and subsequent anastamoses during bypass surgery.