Over the past 11 years, 224 patients (440 limbs) underwent aortofemoral bypass grafting for claudication (63%) or limb-threatening ischemia (37%). The distal anastomosis included the profunda femoris artery directly or only as a profundaplasty in 163 limbs (37.0%). Concomitant distal bypasses were carried out in 19 limbs (4.3%). The perioperative mortality rate was 4.9%; over half of the deaths (six) were from myocardial infarction. There were ten early graft limb occlusions (2.3%). Only five major amputations (1.1%) occurred. Long-term follow-up of 416 limbs averaged 58.5 (range 2-142) months. Cumulative primary and secondary patency rates were 88 and 93% respectively at 5 years, and 73 and 89% respectively at 10 years. The cumulative limb salvage rate was 95% at 5 years and 91% at 10 years. Improvement of claudication or relief from limb-threatening ischemia occurred in 90% of limbs early after treatment. Only 5.9% of limbs were worse after operation. During follow-up, 55 patients (38.5%) died, over half from cardiac causes. Long-term graft-related complications included pseudoaneurysm in 16 limbs (3.8%) and graft limb thrombosis in 33 (7.9%), occurring at a mean of 57.8 and 24.8 months respectively. Graft infection occurred in four patients (1.9%). Excluding operations for graft infection, the operative mortality rate in 72 reoperations on 45 patients was 5.5%. In summary, aortofemoral bypass grafting can be performed safely with excellent long-term patency and limb salvage rates. Improvements in the perioperative mortality rate could best be addressed by improvements in cardiac evaluation and perioperative monitoring. Long-term graft limb complications do occur and, therefore, these patients require lifetime surveillance.