Patients with multilevel atherosclerotic disease represent a difficult surgical challenge. This report is a retrospective review of 46 patients who were treated using a combination of iliac transluminal angioplasty and infrainguinal reconstruction. There were 42 male and 4 female patients with an average age of 62 years (range: 40 to 74 years). Follow-up ranged from 1 month to 10 years (mean: 27.3 months). These patients had multiple health problems typical of patients with peripheral vascular disease, including coronary artery disease (67%), hypertension (61%), and diabetes mellitus (42%); 80% of the patients were smokers. Forty-one patients were treated for rest pain and/or tissue loss, while five were treated for incapacitating claudication. Forty-three patients had a combination of angioplasty and distal bypass, while 3 patients had a form of femoral endarterectomy. Iliac artery pressure gradients were reduced from 35.4 +/- 4 mm Hg preangioplasty to 0.6 +/- 0.3 mm Hg postangioplasty. The procedures were well tolerated with no mortality and four serious complications. Vascular laboratory studies showed an improvement in the mean ankle-brachial index from 0.35 +/- 0.03 preoperatively to 0.71 +/- 0.04 postoperatively (p less than 0.05). Life-table analysis revealed a 72% 5-year primary patency rate, with a 93% 5-year limb salvage. Eight patients required a secondary procedure to maintain limb salvage. Five patients underwent amputation, three due to early graft thrombosis and two due to late graft failure. We conclude that combined iliac angioplasty and infrainguinal reconstruction is a safe and effective method for managing the patient with severe multilevel atherosclerotic disease.