When sufficient vein for a completely autogenous femorotibial artery bypass is not available, composite sequential grafting by using vein combined with polytetrafluoroethylene material is a surgical option. This study reviews what is currently the largest collection of these grafts and focuses on technical aspects and long-term patency characteristics. During a 7-year period 67 composite sequential bypasses were used to manage rest pain (38), ulcer (18), or gangrene (11) in 62 patients (mean age, 66 years). Fifty-two percent were men, and 51% had diabetes. This method was used as a primary reconstruction in 30, a second bypass in 16, and in 21 it was used after multiple other failed bypasses. Femoral to above-knee popliteal (44) and below-knee popliteal (23) 6 mm polytetrafluoroethylene grafts were placed. Then extensions of greater saphenous (57) or lesser saphenous (10) vein were anastomosed to the anterior tibial (19), posterior tibial (26), or peroneal (22) arteries. Fifty-three percent were maintained on long-term warfarin (Coumadin) anticoagulation, and 33% were maintained on aspirin. No deaths occurred in the perioperative period. Bypass patency was ascertained by a Doppler pressure and waveform analysis, with mean follow-up of patency or to the time of graft failure of 33 months (1 to 91 months). Three-year patient survival was 72%. Cumulative life-table primary patency of 72% (1-year), 64% (2-year), and 48% (3-year) was calculated. Two grafts are functioning 7 years after placement. Limb salvage was 84% at 2 years and 70% at 4 years. At the time of failure, five grafts retained a patent venous bypass segment, which allowed prompt reconstruction of the proximal portion. In a comparison of grafts with early failure and those with long-term patency, the SVS/ISCVS runoff score, vein diameter, tibial artery diameter, and coagulation status were similar. However, patients with the popliteal anastomosis above the knee had 2-year patency of 72% compared with 46% for those with below-knee anastomoses. This technique, when possible, appears preferable to an all prosthetic tibial bypass.