Background: Application of tissue engineered vascular grafts for small-diameter artery reconstruction has been a much anticipated advance in vascular surgery. The aim of this study is to assess the effectiveness of small-diameter decellularized vascular grafts in below-knee bypass surgery for diabetic lower extremity ischemia. Methods: Three patients with diabetic lower limb ischemia were admitted to the Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University between May, 2010 and June, 2010. Decellularized porcine arteries with modified surface were implanted in the lower extremity for below-knee arterial revascularization. Imaging examination was performed for assessment of graft mechanical stability and patency at 1 month and 6 months after implantation. Results: At 6 months after implantation, all three grafts were patent with no stenosis or aneurysm formation of the grafts were found on imaging assessment with primary patency rate of 100% (3/3) both at 1 month and 6 months after graft insertion. Conclusion: Decellularized vascular graft with surface modification for the small-diameter artery reconstruction had good clinical results after 6 months follow-up in three patients with diabetic lower limb ischemia. © The Author(s) 2020.