The high flow associated with an arteriovenous fistula has been shown to help maintain patency in small arterial anastomoses. In 37 male patients we created common ostium arteriovenous fistula at the distal tibial or peroneal anastomosis as a part of their arterial reconstruction for threatened limb loss. Limb salvage was achieved in 28. Successful amputations at a lower level than would have been anticipated were performed in three. There was early graft failure in four patients resulting in below-the-knee amputations. This operative approach may be helpful in patients who have had previous revascularization procedures that have failed, who resist the idea of amputation, and who fulfill the angiographic criteria of extremely poor runoff with an absent or deficient pedal arch.