The use of an interposition cuff of vein placed at the distal anastomosis between synthetic bypass conduit and outflow vessel has been advocated to improve patency of lower extremity bypass grafts. Over a three-year period we have performed 43 such bypass procedures: to the above knee popliteal artery (n = 3); below knee popliteal (n = 13), and infrapopliteal arteries (n = 27). There were 20 females and 23 males having a mean age of 70 years (48-84 years). Fifteen patients were hypertensive, 15 were diabetic, and 25 had a history of tobacco use. All cases required limb salvage for rest pain (n = 25), gangrene (n = 10), or ulceration (n = 8) in the absence of suitable autologous vein. Nineteen operations followed a previous failed bypass. Patients were reviewed at six-month intervals. The operative mortality was 8% and two-year primary and secondary patency were 40% and 55%, respectively. Cumulative patency rates were better for first-time grafting procedures than for patients who had undergone previous attempts at limb salvage (60% versus 22%). Two-year limb salvage was 60%. During the same time period, two-year primary and secondary patency rates were 54% and 67%, respectively for autogenous vein. Although the numbers are small these results support the use of an adjuvant vein cuff when employing synthetic grafts. A prospective study of vein versus synthetic graft plus cuff should be undertaken.