Sequential femoral-popliteal-tibial bypass has been recommended for surgical treatment of severe lower limb ischemia in patients with complex multisegmental arterial occlusion. To evaluate this alternative technique critically, sequential grafting was performed in 40 limbs with severe ischemia manifest by rest pain (20), nonhealing ulceration (eight), or gangrene (12). Measurement of segmental Doppler arterial pressure revealed a significant increase in ankle brachial index from 0.29 +/- 0.15 before operation to 0.93 +/- 0.12 after operation, confirming the hemodynamic improvement among these patients. In the early postoperative period occlusion of the distal graft segment was recognized in 12 patients by a characteristic reduction of the ankle/brachial index (0.50 +/- 0.14), while the low thigh pressures remained unchanged. Recurrent severe ischemia was prevented in most by persistent patency of the proximal graft segment. Overall, significant hemodynamic improvement was achieved in 29 of 38 limbs, a limb salvage rate (76%) comparable to that reported for femoral-distal bypass or femoral-popliteal bypass to an isolated popliteal segment. Early graft failure in this series resulted in major amputation in eight of 16 limbs, a significantly lower rate than for these other techniques. Sequential bypass grafting is a useful alternative method for limb salvage. The preservation of the proximal graft patency after distal segmental occlusion may be an important characteristic of this type of reconstruction.