Surgical intervention for aortoiliac occlusive disease (AIOD) remains a vital tool in the management of AIOD. AIOD is caused by occlusion of the infrarenal and/or iliac arteries, often secondary to atherosclerosis. Here, we present a case of a young, male patient with a history of familial hyperlipidemia and chronic tobacco use who underwent a thoracofemoral bypass (TFB) procedure via a retroperitoneal approach. He presented with classic symptoms of bilateral leg pain when walking, nocturnal lower extremity pain, and correlated diminished lower extremity pulses. TFB was the preferred approach due to the aggressive, soft plaque burden extending into the suprarenal aorta, which precluded endovascular repair and would have increased risk for standard infrarenal aortofemoral bypass (AFB). This video and case report present a detailed explanation of a retroperitoneal approach to a TFB procedure and the nuanced indications of the surgical interventions for AIOD.1,2