In certain patients the standard bypass procedure for aortoiliac occlusion is unsuitable. Included in this group are those who are obese, who have horseshoe kidneys, abnormal renal arteries, large incisional hernias, thoracoabdominal coarctation, failed previous aortoiliac repair or who have undergone multiple laparotomies. Since 1975 the authors have operated on 16 such patients to construct a bypass graft from the ascending aorta to the femoral arteries without entering the abdominal cavity. The new ventral aorta follows the natural anastomotic axis of the mammary and epigastric arteries, behind the rectus muscle and in front of the posterior rectus sheath. The operation is simple and effective and is especially applicable to the patient with obstruction of both the coronary and aortoiliac arteries.