Thomas shunts have been utilized 24 times in 20 patients to provide secondary vascular access in an often poor-risk group of patients, including children. Twenty of the shunts were on the iliac vessels. Five shunts are in current use, the longest having been in situ for 83 months. Another 13 shunts provided access until renal transplantation or death of the patient. Six shunts developed deep infection which usually extended to the Dacron-arterial anastomosis; the management of these infected iliac shunts was difficult and hazardous. No definite advantage for the iliac placement of shunts has been established, and its use at this site cannot be recommended. Although the Thomas shunt can provide good long-term access, our experience suggests that its use should be limited to that of a "shunt of last resort".