A histological study was made of the small pulmonary blood vessels in pieces of lung obtained at necropsy from 19 long-term residents of La Paz, Bolivia (3800 m). There was variation in the response of the pulmonary vasculature of these subjects to the chronic hypoxia of high altitude. The most characteristic finding, seen in seven of the 16 cases beyond infancy, was distal extension of vascular smooth muscle into pulmonary arterioles as small as 20 μm in diameter. Medial hypertrophy of the muscular pulmonary arteries occurred in only three of these seven subjects. Intimal fibrosis was seen in eight of the 19 cases and was ascribed to age; such fibrotic proliferation may affect the reversibility of hypoxic pulmonary hypertension and associated vascular changes in highlanders.