OBJECTIVE Arterial bypass from the descending thoracic aorta to the femoral system provides successful perfusion when an approach to the abdominal aorta is undesirable. This review of a large series with a decade of experience was conducted to better define patency data and the natural history of patients after this operation. METHODS During a 10-year period, 21 patients, 18 men and 3 women (mean age 57 years), underwent descending thoracic aorta to left femoral artery bypass with femorofemoral bypass. These were placed to convert axillopopliteal or axillofemoral grafts (12 patients) to a more permanent inflow source. The axillary bypasses had been previously placed to allow removal of infected aortic grafts and had undergone a total of 14 revisions or thrombectomies before conversion. In addition, patients had this procedure after multiple failed attempts (at least two) at intraabdominal aortic repair (five patients) or to avoid exploration of the abdomen after extensive retroperitoneal dissection or radiation (four patients). Surgical technique involved a seventh interspace thoracotomy with a transdiaphragmatic retroperitoneal anterior axillary line tunnel to the left groin. RESULTS There was no perioperative mortality. The mean hospital visit was 15.1 days and intensive care stay 4.3 days. There was no perioperative myocardial infarction, stroke, or renal failure that necessitated dialysis. With a follow-up period of 1 to 121 months (mean 44), the 4-year patency rate was 100%. A single graft failed at 49 months but was renewed by thrombectomy and femorofemoral bypass. Thus the extended patency rate was 86%, but the secondary patency rate remained 100% throughout. Since the thoracic operations, patients have required five femoropopliteal, three femorotibial, two profunda, and two femorofemoral operations. CONCLUSIONS Descending thoracic aorta-to-femoral artery grafting is a safe, extremely durable arterial bypass configuration. It is an excellent reconstruction for survivors of aortic graft infection, those who have had multiple failures of aortic grafts, and patients for whom abdominal exploration would be hazardous.