Thoracic aortic to infrainguinal arterial bypasses are rare in the literature, even more so when the outflow is the popliteal artery bilaterally. The case of a patient presenting with critical limb ischemia, chronic infrarenal aortic occlusion, and recurrent thrombosis of a unilateral axillobifemoral graft managed with thoracoretroperitoneal bitransobturator bipopliteal bypass is presented. The patient's vascular history was significant for multiple previous groin procedures for thrombectomy of her axillobifemoral graft, aortomesenteric bypass, redo aortomesenteric bypass for graft thrombosis, and multiple bowel resection procedures for acute mesenteric ischemia. The thoracic aorta and popliteal arteries were selected as sites for proximal and distal anastomoses, respectively, given anticipated difficulty in exposing the supraceliac aorta and femoral arteries. The technique of this operative approach is discussed.
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