Background: Patients with severe peripheral arterial disease with limited or nonexistent arterial runoff, the so-called “desert foot”, challenge efforts at limb preservation. Deep vein arterialization (DVA) involves incorporating a venous target as an outflow to achieve revascularization in these complex patients. We report outcomes in an initial series of patients undergoing DVA as a component of surgical bypass. Methods: Over a 2-year period, 10 patients underwent bypass incorporating DVA due to severely disadvantaged runoff using a heparin-bonded expanded polytetrafluoroethylene conduit. Indications for surgery included tissue loss (8) or ischemic rest pain (2) in patients who had failed endovascular (3) or surgical (7) revascularization. Inflow arteries for bypass ranged from external iliac to below knee popliteal. Outflow anastomoses incorporated a common ostium arteriovenous fistula between anterior tibial (5), posterior tibial (2), peroneal (1) or plantaris pedis (2) arteries, and corresponding tibial veins. Prior to anastomotic completion, tibial vein valves were lysed to allow venous arterialization by a way of retrograde flow. Postoperative medical regimen included dual antiplatelet (2), antiplatelet plus anticoagulation (7), or anticoagulation alone (1). Results: Primary patency was maintained in 7 of 10 grafts (average: 4.1 months, range: 1–18 months). Limb salvage was achieved in 8 of 10 patients (average: 6 months, range: 1–18 months). Two below knee amputations were performed after graft occlusion due to extensive tissue loss and infection, whereas 1 patient maintained limb salvage despite graft occlusion after successful wound healing. Conclusions: This initial experience describes surgical DVA using a prosthetic conduit in conjunction with an arteriovenous fistula at the distal anastomosis in patients with threatened limb loss and severely disadvantaged tibial runoff. Although evidence for long-term efficacy is uncertain, preliminary outcomes warrant further investigation as this technique may allow for surgical revascularization resulting in limb preservation for patients with no other alternative than amputation.