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The incidence of distal anastomotic hyperplasia (DAH) in superficial femoralpopliteal veins (SF-PVs) used as femoropopliteal bypass (FPB) grafts was investigated, with particular reference to the form of distal anastomotic construction. Seventy-seven SF-PV grafts that met specific angiographic follow-up criteria qualified as "studied" grafts. DAH was identified in 13 (17%). Cobra head anastomoses, 2 cm or less in length, were used in 21 grafts and yielded 6 instances of DAH (29%). When 8 sharply tapered 3 cm (swordfish) anastomoses were constructed, 3 grafts (37.5%) developed DAH. With 3 cm moderately tapered (fishmouth) anastomoses in 48 grafts, DAH was seen 4 times (8%). Because the distal 1 cm of the swordfish configuration was very narrow, the swordfish and cobra head constructions were functionally equivalent and were grouped together as "short" anastomoses. The difference in the incidence of DAH with long and short anastomoses, 8% vs 31%, was statistically significant (p = .016).In the 48 "studied" grafts with fishmouth anastomoses, the occurrence of all 4 DAHs among the 15 female diabetic limbs was also significant (p = .019).Constructing 3 cm moderately tapered anastomoses significantly reduced the incidence of DAH, the leading cause of graft failure, in SF-PV FPB grafts. The achievement of primary and assisted patency rates of 84% and 91% at both three and five years in the 93 SF-PVs placed as primary FPB grafts since October, 1982, was largely due to the reduction in DAH that resulted from anastomotic modification.