Background: In recent years, percutaneous transluminal angioplasty (PTA) has been preferred to surgery in elderly patients with PAD who are more prone to concomitant diseases. We report our experience with PTA via a bypass graft vessel to treat a case of total occlusion of both the superfi cial femoral arteries in a patient who additionally contracted Leriche syndrome due to an aorto-iliac occlusion after receiving a left axillo- bifemoral graft. Case: A 67-year-old man received a left axillo-bifemoral graft at another hospital for aorto-iliac occlusion (Leriche syndrome) 11 years ago. He was referred to the cardiovascular department because of bilateral claudication symptoms and blue toe syndrome that he developed after walking over 200 m (Rutherford category 2). He had no past medical history of diabetes mellitus, hypertension, or dyslipidemia, except for a 50 pack/year history of smoking. His physical examination revealed the absence of pulses below both the popliteal arteries. The ankle brachial index (ABI) scores while resting were 0. 53 and 0. 67, and the ABI scores while exercising were 0. 26 and 0. 35, on the right and left sides, respectively. Enhanced lower extremity computed tomography angiography(CTA) revealed a distinct left axillo-femoral bypass graft and a total obstructive lesion at both SFAs just below the anastomotic site of the bypass graft vessel and femoral arteries. We performed PTA of right superfi cial femoral artery via a left axillo-bifemoral graft vessel. The second PTA for left superfi cial femoral artery was performed 6 months later. After the second PTA, the follow-up ABI improved from 0. 68 to 0. 78, and the claudication of both legs had also improved. The patient showed rapid improvement in his symptoms and complained only of mild claudication (Rutherford category 1).