The treatment of failing bypass grafts is difficult because repeat surgery carries a higher mortality rate than a first operation. Percutaneous intervention is more difficult because mechanical manipulation of these soft, friable atherosclerotic plaques have been associated with a significant rate of distal embolization, myocardial infarction, late restenosis and death. Balloon angioplasty alone has proven to have serious limitations in the treatment of older degenerated saphenous vein grafts (SVG). Although directional atherectomy yielded a higher angiographic success in a randomized trial, the restenosis rate was similar, and the procedural complications higher. The transluminal extraction catheter (TEC) has also shown significant limitations for the treatment of degenerated or thrombotic vein grafts with a significant procedural complication rate. A randomized trial comparing stenting versus balloon angioplasty in focal SVG lesions showed a higher freedom from major adverse cardiovascular events in the stent group, but there was no significant difference in the angiographic restenosis rates. More recently, rheolytic thrombectomy and mechanical thrombolysis have proven useful in treating thrombotic lesions in SVG. In addition, the recent development of distal protection devices appears very promising and will probably contribute to decreased distal embolization during percutaneous revascularization of these conduits.