Results of infrainguinal bypass for limb salvage in patients with end-stage renal disease. Limb salvage in patients with end-stage renal disease (ESRD) is complicated by the diffuse, obstructive, calcific arteriopathy that makes anastomotic technique especially critical. Furthermore, decreased resistance to infection and impaired wound healing produced by host-factor deficiencies such as diabetes mellitus, hypoalbuminemia, uremia, and immunosuppression produce additional obstacles to successful limb salvage. This report summarizes our experience with distal arterial bypass procedures in these patients. A total of 32 bypass procedures were performed for limb salvage in 24 patients (17 diabetic) during a period of 5 years. The operative mortality rate was 6%. During the same period, 635 infrainguinal bypass procedures were performed by the in situ technique in patients without ESRD. Primary bypass patency was comparable in both groups at 24 months (92% vs 90%). In the group with ESRD, overall limb salvage was 83% at 2 years. Life-table analysis of bypass patency and limb salvage was thought not to be appropriate in the population with ESRD beyond 2 years because of the increased mortality rate (38%; 9/24) during this interval. It is important that limb salvage was achieved in diabetic patients with ESRD in the presence of extensive foot gangrene or ischemic ulceration. Revascularization should be considered strongly for limb salvage in all patients in this difficult population. 