Since the first successful use of an autogenous vein graft for arterial reconstruction by Gluck in 1898 and the establishment of the scientific basis for the use of veins as arterial substitutes by Carrell and Guthrie in the early 1900s, reversed autogenous veins have been used extensively in arterial reconstructive operations. Despite being the preferred material for reconstruction, reversed autogenous vein is not an ideal graft material. The primary problem is structural alterations in the implanted vein predisposing to graft failure. Most of these failures occur within the first few months after graft implantation and are though to be due, in part, to endothelial damage incurred during harvesting and preparation of the vein. This review focuses on technical aspects of vein graft harvesting associated with alterations in endothelial morphology including dissection technique, types of irrigation and storage solutions used, temperature of these solutions, distension pressures, and pharmacologic agents. An optimal technique incorporating subcutaneous and perivenous infiltration with papaverine, atraumatic dissection, controlled gradual distension, and storage of the distended vein in cold heparinized blood containing papaverine should produce grafts with improved endothelial preservation and patency rates compared with grafts harvested by techniques in widespread use at present. The importance of morphologically and functionally intact endothelium in reversed vein grafts, a comparison to that produced by in situ vein grafting, and its possible clinical implications are discussed.