From January 1980 through December 1988, 564 limbs in 434 patients were treated for infrainguinal arterial ischemia. Of these, 516 limbs in 387 patients underwent reversed vein bypass grafting. The remainder were treated by primary amputation (11 limbs, 1.9%) or by prosthetic bypass (37 limbs, 6.4%). The indications for operation were limb salvage in 80% of limbs and claudication in 20%. Adequate ipsilateral greater saphenous vein was available for 285 (55%) grafts, with reversed vein bypass achieved in the other 231 operations by use of distal graft origins (151 grafts), use of alternate vein sources (120 grafts), and splicing of venous segments (81 grafts). Seventy-six grafts (15%) were to the above-knee popliteal artery, 199 grafts (37%) were to the below-knee popliteal artery, and 241 grafts (47%) were to infrapopliteal arteries, 26 of which (11%) were to inframalleolar arteries. The primary and secondary patencies for all grafts at 5 years were 75% and 81%, respectively. Grafts to infrapopliteal arteries had significantly worse primary patency (69%) at 5 years than did grafts to the popliteal artery (77%, above knee; 80%, below knee) and grafts formed of adequate ipsilateral greater saphenous vein had significantly better primary patency (80%) than did grafts performed when this conduit was not available (68%). Secondary patency of all graft categories ranged from 76% to 85%, and there were no significant differences regardless of site of distal anastomosis, source of venous conduit, or site of graft origins. We prefer the use of reversed vein bypass grafting for lower extremity revascularization both because of the excellent patency results and because the technique can be applied to the larger number of patients in our practice who lack intact ipsilateral greater saphenous vein, in contrast to in situ vein bypass procedures.