This review identifies the causes of PTFE infrainguinal bypass graft failure and compares the results of management alternatives. In 322 infrainguinal reconstructions 111 failures occurred over a ten year interval (1978-1988). Sixty-four percent of all failures occurred within the first year, most within the first six months due to severity or progression of distal disease (56%), which suggests that patient selection is an important factor. Only 8% of cases had intimal hyperplasia as a cause of failure without evidence of distal disease progression, and all occurred within the first twelve months. Progression of inflow disease occurred in 25% of instances and was most commonly seen as progression of iliac disease in patients operated upon to relieve claudication and thrombosis of inflow reconstructions in limb salvage patients. Infection was the cause of failure in 5.5% of failed grafts (1.8% of the series) and was associated with multiple reoperations. Management consisted of conservative treatment in 15 cases, with amputation resulting in seven (46%) of these. Operative treatment consisted of (A) thrombectomy with or without patch (N = 56); (B) extension with vein (N = 12); (C) replacement with vein (N = 11); or (D) extension or replacement with PTFE (N = 17). Primary patency and limb salvage of secondary procedures at 30 months after the reoperation was (A) 40%/45%; (B) 32%/43%; (C) 55%/72%; and (D) 30%/38%, respectively. Patients in Group C (replacement with vein) had an 88% 30-month patency when this was the first procedure after the failure, with limb salvage in all cases.(ABSTRACT TRUNCATED AT 250 WORDS)