Abstract Background We sought to evaluate the role of balloon angioplasty as the primary modality in the management of vein graft stenoses. Methods Patients who underwent infrainguinal vein graft bypass from January 2002 to December 2007 were enrolled into a surveillance program. Grafts which developed critical stenoses were identified and underwent urgent angiography with a view to angioplasty of the stenotic lesion. Lesions which were deemed unsuitable for angioplasty underwent urgent surgical repair. Results Four hundred and eleven grafts were followed up for a median of 19 months (range: 2–61). Ninety-six grafts (22.6%) developed critical stenosis. Twelve grafts occluded prior to repair and one was not intervened upon electively. Eight grafts underwent primary surgical repair. Seventy-six grafts underwent 99 endovascular procedures. Technical success was achieved in 60 grafts (78.9%). Of the grafts in which technical success had not been achieved, eight underwent repeat angioplasty and three were surgically repaired. Twenty-four grafts underwent repeat angioplasty for re-stenosis with a technical success rate of 71%. No difference was observed in graft patency ( P = 0.08) or amputation rates ( P = 0.32) between the grafts requiring intervention to maintain patency, and grafts which did not. Smoking [OR: 2.61 (95% CI: 1.51–4.53), ( P = 0.006)], diabetes [OR: 2.55 (95% CI: 1.49–4.35), ( P = 0.006)], renal failure [OR: 1.89 (95% CI: 1.19–3.38), ( P = 0.040)] and recurrent stenosis [OR: 3.22 (95% CI: 1.63–4.69), ( P < 0.001)] were risk factors for graft occlusion. Conclusions Balloon angioplasty of failing infrainguinal vein bypass grafts is safe and can be performed with an acceptable medium term patency rate, albeit with a significant risk of re-stenosis which can be successfully treated in most patients using repeat endovascular intervention.