Bypass from the descending thoracic aorta to the femoral arteries is well described but infrequently used as a method of revascularization for lower extremity ischemia caused by aortoiliac occlusive disease. Descending thoracic aorta to femoral artery bypass has been traditionally used as a remedial operation after aortic or axillofemoral graft failure or graft infection or when a direct aortic approach is not possible. An expanded role for descending thoracic aorta to femoral artery bypass for primary revascularization in the presence of severe calcified atherosclerotic disease or complete occlusion of the infrarenal aorta should also be considered. This chapter reviews the historical background, operative technique, surgical indications, and clinical results of the operation. © 1999, Sage Publications. All rights reserved.