Clinical and anatomic considerations for surgery in tibial disease and the results of surgery. Bypass vein grafts to the infrapopliteal arteries now achieve a 5-year cumulative patency equivalent to that of vein grafts to the popliteal arteries. The technique of in situ vein grafting to the tibial arteries is described and the results are presented. The 5-year cumulative patency for such bypasses and the 5-year limb salvage in the same patients have both been approximately 80%. These results coupled with those reported from other centers that have sizable experience in tibial artery reconstruction suggest that there has been real progress over the past decade in the salvage of lower extremities in patients with far advanced peripheral vascular disease through the use of autogenous venous bypass grafts. 