Bypass grafting to distal lower extremity vessels continues to be associated with a high rate of graft occlusion. By utilizing a sequential side-to-side anastomosis between saphenous vein and popliteal artery in femoral-tibial bypass grafts, runoff can be increased and graft patency thereby improved. Sequential femoral-tibial grafts were employed in seven patients with gangrene, trophic changes, or restpain, all of whom had single-vessel runoff by arteriography. All seven sequential grafts established to a distal vessel in addition to the popliteal artery have remained open for periods of five to 27 months as determined by palpable graft or foot pulses. Two patients underwent below-knee amputation within six months of operation but had patent grafts at the time of amputation. In three patients ischemic ulcers resolved and in two patients toe amputations healed successfully. Sequential bypass grafting is a technique aimed at improving the patency rate of femoral-tibial bypass grafts by augmenting runoff.