Objective To determine the safety and midterm efficacy of hybrid surgery for complex Trans-Atlantic Inter-Society Consensus (TASC) type D iliac and femoral occlusive lesions. Methods Twenty-seven patients with complex type D iliac and femoral lesions admitted in our department from January 2007 to December 2013 were recruited in this study. According to the results of computed tomography angiography (CTA) and TASC recommendation, the patients were assigned into groups of aorto-iliac C type plus femoropopliteal D type segment lesions (n=14), aorto-iliac D type plus femoro-popliteal C type segment lesions (n=7), and aorto-iliac D type plus femoro-popliteal D type segment lesions (n=6), and all of them underwent hybrid surgery for aorto-iliac and femoro-popliteal lesions simultaneously to improve the inflow and outflow. Ankle-brankial index (ABI) before and in 6,2, 24, and 36 months after surgery, and preoperative and postoperative patency rates (12,4, and 36 months) were recorded and analyzed. SPSS statistics 16.0 was used to perform the statistical analysis. Student’s t test was employed in intergroup comparison for measurement data. Kaplan-Meier survival analysis was adopted to analyze the patency rate. Results For aorto-iliac lesions, aorto-femoral artery bypass, iliac artery stenting, crossover femoro-femoral bypass, and endarterectomy or thrombectomy were performed respectively or in combination. For femoro-popliteal lesions, femoro-popliteal bypass, endarterectomy, femoral profundaplasty, thrombectomy, balloon dilatation and stent implantation were chosen respectively or in combination. No peri-operative death or major complications was observed. ABI was significantly increased in 6,2, 24, and 36 months after surgery (0.91±0.16,0.85±0.14,0.82±0.17, 0.77±0.13 vs 0.47±0.24, P<0.01). The patency rate was 95.7%, 80.2% and 72.9% respectively in 12,4, and 36 months postoperatively. Conclusion Hybrid surgery is safe and has good midterm outcomes for the patients with complex type D iliac and femoral lesions, especially for high-risk older patients.