Autogenous vein has been used as a bypass conduit for inframalleolar grafts in patients with vascular occlusive disease. Acceptable patency and limb salvage have been achieved in most patients. However, in patients with end stage renal disease (ESRD), the results have been less satisfying. Autogenous artery can be used as a bypass conduit and posseses several advantages over vein conduits when bypassing to small vessels less than 5 mm in diameter. Arterial conduits are technically easier to suture microscopically and their taper is anatomic, progressing from large proximally to small distally. Patients with end stage renal disease and arterial lesions distal to the malleolus were included. Thirteen patients received autogenous arterial grafts. Eleven of these have end stage renal disease with six being on chronic hemodialysis. Three of the patients have a creatinine greater than 6.0 and two had functioning renal transplants. Of these eleven patients with ESRD, five received an autogenous arterial conduit graft to augment blood flow to the foot while six received a longer graft consisting of a vein graft, which was lengthened on its distal end with an arterial conduit graft. The patient study profile consisted of nine males and two females. The average age was 51 years. All of the patients had tissue loss or gangrene prior to the bypass. Six of the patients had diabetes mellitus, ten had hypertension, two had cardiac disease and two were smokers. Of the eleven grafts, nine remained patent two years post-operatively. Two grafts clotted within one week of surgery, presumably due to poor run-off. These two patients subsequently received below knee amputations. Of the nine patients with patent grafts, four received digital amputations and two received transmetatarsal amputations for pre-existing gangrene. The remaining three patients received local wound care for pre-existing ulcers. All original tissue wounds were healed twelve weeks following the vascular bypass. Postoperative blood flow studies showed the mean ABI increased from 0.26 to 0.65. The mean toe pressure increased from 0.13 to 0.37. At three years, the assisted primary patency was 82% while the functional limb salvage was also 82%. In conclusion, autogenous arterial conduit grafts provide good patency results in these difficult patients with ESRD. The technical ease and anatomic taper of arterial conduits contributes to their patency.