Distal arterial grafting for limb salvage remains controversial. Among the criticisms is the potential adverse effect of failed distal bypass on subsequent amputation level. Measurement of popliteal pressure with Doppler ultrasound is useful in predicting healing at the below-knee (BK) level and, pressure of greater than or equal to 60 mm Hg was associated with 87% BK healing in 51 limbs undergoing amputation without prior distal bypass. This study examined the outcome in 40 limbs amputated after unsuccessful distal revascularization and compared the final amputation level with that predicted by popliteal pressure measurements obtained prior to bypass. Forty limbs underwent amputation after unsuccessful limb salvage following attempted femoropopliteal grafts (13), femorotibial grafts (10), a combination of both procedures (10) or tibial artery exploration alone (7). Of 33 limbs with initial pressure of greater than or equal to 60 mm Hg, eventual healing at the BK level was achieved in only 17 (52%). Four of seven limbs with initial pressures of less than 60 mm Hg healed at the BK level, and increased popliteal pressure prior to amputation was shown in three of these. Of the total 40 limbs, only 21 (53%) obtained final healing at the BK level. These results indicate that unsuccessful limb salvage attempts adversely affected ultimate amputation level in limbs initially considered to be candidates for BK amputation.