Multilevel occlusive vascular disease presenting with gangrene. The medical records of all patients subjected to lower extremity amputations during a 3-year period were reviewed. It was shown that advanced age and the presence of multiple medical problems do not predispose to higher levels of limb loss. Although diabetic patients more frequently undergo amputation because of sepsis than their nondiabetic counterparts, the diabetic state was not found to be associated with a greater likelihood of above knee (AK) procedures. Prior arterial surgery was not shown to make AK amputation more likely, but it was disconcerting to note that limb salvage was not achieved in many individuals despite patent proximal inflow revascularization procedures. This initial study showed that several presumed risk factors were not predictors of amputation level. Those patients requiring AK amputations had a greater frequency of combined segment (aortoiliac and femoropopliteal) occlusive disease than those who had successful amputations at more distal levels. A follow-up study of 41 consecutive patients presenting with tissue loss due to combined segment occlusive disease was performed. Eighteen (Group I) underwent inflow procedures only, while 23 (Group II) also underwent distal revascularization. The groups were similar with respect to age, risk factors, extent of tissue loss and sepsis. At 1 year 10 (56%) Group I and only 3 (13%) Group II patients required major amputation (P = 0.01). Distal bypass, in addition to an inflow procedure, is recommended for those who present with tissue loss due to multilevel arterial occlusion. 