This chapter describes the current approaches toward small-diameter tissue-engineered vascular grafts. The outstanding problem of failure for grafts smaller than 4 mm diameter remains a challenge and requires a multidisciplinary approach. The perspectives of tissue engineering, surface modification, bioengineering, and emerging technology are discussed. The unifying themes are to mimic the native extracellular matrix, provide a favorable surface for cell proliferation, and develop a functional and confluent blood-contact surface. Continued efforts to produce a demonstrably functional small-diameter vascular graft are desperately needed.