Available endovascular and less invasive surgical interventions have diminished the need for aortofemoral bypass (AFB) construction for chronic inflow occlusive disease but have potentially increased its complexity. We reviewed our results with AFB done in 107 consecutive patients between 1997 and June 2002 (83 men, 24 women, mean age 62 +/- 7 years) with chronic limb ischemia due to aortoiliofemoral occlusive disease. Perioperative factors and surgical outcomes (<30 days) were evaluated and compared between patients requiring complex (redo AFB, need for visceral aortic clamp for juxtarenal occlusion, adjunctive visceral revascularization, or simultaneous inflow/outflow bypass) and conventional reconstructions by contingency table analysis. AFB was done for limb threat in 65 patients (61%) and 44 patients (41%) had failed previous inflow procedures (22 endovascular, 43 open; 1.5/patient). Operative complexity (36 patients, 34%) was evidenced by the need for redo AFB in 8 patients, suprarenal (13) or supramesenteric/celiac (6) aortic clamp and pararenal endarterectomy in 19 cases, adjunctive renal (10) or mesenteric (2) revascularization, or simultaneous construction of AFB and femoropopliteal/tibial bypasses in 9 patients. Overall AFB operative mortality and major complication rates were 3.7% ( n = 4) and 34% ( n = 36), respectively. Mortality ( p = 0.32) and nonvisceral related complications ( p = 0.3) were not statistically more frequent after complex AFB (5.6%, 31%) than after conventional reconstructions (2.8%, 21%). However, renal, mesenteric, or spinal cord (visceral) ischemic complications or death (10.3%) were greater after complex reconstructions (19.4%) than after conventional AFB (5.6%) ( p = 0.03). Pre-existing renal insufficiency (Cr >/=1.5, n = 9) was not predictive of postoperative renal failure (>2x preop Cr, n = 7) in this series ( p = 0.4). Our recent experience with AFB suggests its increasing use as a tertiary modality after failed endovascular or less invasive open reconstructions. Despite the added operative complexity associated with manipulation of the visceral aorta and its branches and the need for extended infrainguinal revascularization, satisfactory clinical outcomes can be achieved.