Intravascular ultrasound (IVUS) has emerged as a useful and often necessary adjunct in a rising number of catheter-based peripheral interventions. IVUS catheters enable luminal and transmural cross-sectional imaging of peripheral vessels with high dimensional accuracy and provide detailed information about lesion morphology. IVUS is able to guide the optimal choice of appropriate angioplasty technique, guide the delivery of endovascular devices, and assess the immediate outcome of an intervention. In this review we discuss the role of IVUS for peripheral occlusive diseases, specifically the application of IVUS technology during percutaneous transluminal angioplasty (PTA), intravascular stent placement, crossing total occlusions, and venous obstructive disease.