BACKGROUND Today, saphenous veins are most frequently used to reconstruct occluded or diseased small diameter vessels (< or =6 mm in diameter). However, these veins are unavailable in 30-40% of patients. In such a situation, prosthetic grafts provide the only alternative. Since an endothelial cell (EC) lining, important for maintaining a haemostatic-thrombotic balance, does not develop onto the intima of implanted grafts in humans, these grafts occlude within a short period of time. The failure of vascular grafts is attributed to their characteristics which are nonconducive towards endothelial cell adhesion, spreading and growth. In order to examine whether the patency of vascular grafts can be improved by the surface modification of grafts' intima, small diameter grafts were modified by a novel ammonia plasma treatment to enhance their interactions with EC. METHODS Through laparotomy, ammonia plasma treated ePTFE (4 mm in diameter) grafts (n=3) and control untreated grafts (n=6) were implanted into the distal infrarenal aorta of rabbits. At appropriate time, grafts and adherent tissue were removed, fixed, stained and embedded in Poly/Bed 812. Light microscopic examination of thin sections cut from the proximal and distal anastomatic and midportion segments of explanted grafts was carried out. RESULTS In control group studies, all animals developed lower limb paraplegia within seven days of implantation. Light microscopic examination of explanted control grafts showed that control grafts were obstructed by thrombosis/intimal hyperplasia. However, ammonia plasma modified explanted grafts, after one month of transplantation, revealed an endothelial cell-like lining that covered the grafts' inner surfaces. Accordingly, these grafts remained patent in animals. CONCLUSIONS The grafts' surfaces that are made conducive to EC adhesion and proliferation and host response may influence endothelial regeneration. It is hoped that the combination of angiogenic molecules (i.e. endothelial cell specific growth factors such as VEGF) with ammonia plasma modified grafts may provide further insight into the development of ideal small diameter prosthesis.