BACKGROUND Descending thoracic aorta-to-femoral artery (DTAFA) bypass graft is an alternative procedure to revascularize lower limbs. METHODS Between 1976 and 1996, 41 patients underwent DTAFA bypass grafts. Operative indications consisted of previous abdominal graft thrombosis (22 cases, group 1), abdominal operations (8, group 2), initial vascular operation in the presence of difficult aortas (6, group 3), and infection of aortic grafts (5, group 4). RESULTS Perioperative mortality was 5%. Cumulative 10-year primary patency, limb salvage, and survival rates were 64%, 79%, and 55%, respectively. Breaking down the result on the basis of the four groups, DTAFA bypass grafts performed for infection of previous aortic grafts had a significantly lower primary patency rate (25% at 24 months; P < 0.004) with dismal limb salvage (31% at 24 months; P < 0.001) and survival rates (0% at 24 months; P < 0.005). CONCLUSIONS DTAFA bypass grafts can be safely and durably used in patients who had thrombosis of previous abdominal grafts or had a difficult abdomen or as the initial vascular operation in the presence of difficult aortas. Conversely, dismal results are obtained in the treatment of aortic graft infection.