A 65 old man, developed an acute abdomen four days after an aorto-bifemoral bypass. A CT angio disclosed an occlusion of the superior mesenteric artery (SMA) and an urgent laparotomy, with the patient in septic shock, showed multiple small bowel perforations with extensive peritonitis (Figure 1). To revascularize the SMA, a non-previously described hepatic artery-SMA reversed saphenous vein bypass was performed (Figure 2). An extensive resection of the small bowel left the patient with 50 cm of proximal jejunum, 40 cm of distal ileum, a jejunostomy and ileostomy. A planned second look laparotomy at 24 hours showed an ischemia of the jejunal stoma requiring a resection of another short segment of the jejunum and a new jejunostomy. The patient was treated with TPN, an oral hyposmolar diet and a short course of octreotide. After 6 months, we attempted a reconstitution of the small bowel continuity with a jejunal-ileal anastomosis, which failed. The patient was taken back to the operating room, another 20 cm of the proximal jejunum was removed and a jejunum transverse colon anastomosis was done (Figure 3). Gastrographin study showed an accelerated transit time (Figure 4). Night TPN and daily oral diet with macro- and micro-nutrients supplements were used to support the patient’s nutritional status. Three months after surgery the patient is home with a combination of parenteral and enteral nutrition and three or four bowel movements a day.