Expanded polytetrafluoroethylene (PTFE) grafts have shown promise in bypasses to the popliteal and tibial arteries, but a significant incidence of immediate and late graft failure has limited general acceptance. Compliance differences between the PTFE graft and artery may present technical difficulties in small vessel anastomosis, as well as being implicated in late development of intimal hyperplasia. A retrospective study of 68 patients who had bypass to the distal popliteal and tibial arteries using PTFE grafts with adjunctive distal patch angioplasty was undertaken. Operation was done for limb salvage in 85%. Runoff was marginal in 69%. A venous patch was sutured to the distal artery and the PTFE graft was then sutured into an opening in the proximal portion of the patch. There was one early graft occlusion. Cumulative patency was 97% at 1 month, 92% at 3 months, 87% at 6 months, 74% at 12 months, and 65% at 24, 36, and 48 months. A distal autogenous vein patch permits precise suturing of the distal anastomosis and minimizes technical difficulties leading to early graft failure. Improvement of the compliance mismatch of the PTFE graft and artery may impede the unwelcome development of intimal hyperplasia at the distal anastomotic site. The adjunctive use of a distal patch has resulted in excellent immediate graft patency, despite a high incidence of poor run-off and limb salvage situations.