In the elderly, revascularization of a severely ischemic lower extremity with occlusion of both femoral and popliteal arteries often can be achieved by surgical construction of a distal bypass to the tibial or peroneal arteries. An aggressive diagnostic and therapeutic approach is necessary, in an attempt to prevent recourse to primary amputation. Femoroperoneal or femorotibial bypass can be performed safely and is recommended in elderly patients with advanced ischemia of a lower extremity with absolute indications for surgical intervention, e.g., gangrene, gangrenous ulceration or rest pain. A significant number of limbs can be salvaged by this method. Although the mortality rate in the older age groups is predictably higher, the overall rate for this operation compares favorably with that for primary amputation.