Background Although aortoiliofemoral bypass grafting is the optimal revascularization method for patients with severe aortoiliac occlusive disease (AIOD), previous studies have documented poor patency rates in young adults. This study investigated whether young patients with AIOD have worse outcomes in patency, limb salvage, and long-term survival rates after reconstructive surgery than their older counterparts. Methods Patients aged ≤50 years undergoing reconstructive surgery at our institution for AIOD between 1995 and 2010 were compared with a cohort of randomly selected patients aged ≥60 years (two for each of the young patients, matched for year of operation), analyzing demographics, risk factors, indications for surgery, operative details, and outcomes. Results Among 927 consecutive patients undergoing primary surgery for AIOD, 78 (8.4%) aged ≤50 years (mean age, 48.4 years) and 156 older control patients (mean age, 71.2 years) were identified. The younger patients were mainly men (81%) and 59% had surgery for limb salvage and 41% for disabling claudication (P = .02). Compared with older patients, they were significantly more likely to be smokers (90% vs 72%; P = .002) and had previously needed significantly more inflow procedures (28% vs 16%; P = .03). Only one death occurred perioperatively (30-day) among the control patients, and no major amputations or graft infections occurred in either group. The need for subsequent infrainguinal reconstructions was greater in the younger patients (18% vs 7%; P = .01). The primary patency rates were inferior in the younger patients at 5 years (82% and 75%) and 10 years (95% and 90%; P = .01), whereas assisted secondary patency (89% and 82% vs 96% and 91%; P = .08), secondary patency (93% and 86% vs 98% and 92%; P = .19), limb salvage (88% and 83% vs 95% and 91%; P = .13), and survival rates (87% and 76% vs 91% and 84%; P = .32) were comparable in the two groups. Conclusions This study shows that despite a higher primary graft failure rate than that in older patients, aortoiliofemoral revascularization for complex AIOD is a safe procedure for younger patients with disabling claudication or limb-threatening ischemia, providing they are willing to follow a regular protocol to complete their postoperative surveillance and to undergo graft revision as necessary.