Distal intraoperative transluminal angioplasty (IOTLA) combined with femorotibial bypass was performed in three patients. All three patients were elderly diabetic men with multilevel occlusive disease associated with rest pain and ischemic lesions of the feet. IOTLA allowed recanalization of segmentally occluded distal vessels or dilatation of multiple distal severe stenoses. These lesions would have been inaccessible to usual percutaneous angioplasty techniques because of intervening occlusions in the thigh. The technique and instrumentation of IOTLA are described. All patients had intraoperative prereconstruction and completion arteriography. In femorotibial bypass grafting, the adjunctive use of IOTLA improved runoff and graft patency to target vessels that would otherwise have been unsuitable. Although the experience is limited and the follow-up period short, the early results are encouraging; the technique deserves further investigation.