The aim of this study was to assess the role of three-dimensional rotational venography (3D RV) supplementary to two-dimensional (2D) digital subtraction venography (DSV) in evaluation of the left iliac vein in patients with chronic lower limb edema. We reviewed 34 patients with chronic lower limb edema who had undergone bilateral iliac 2D DSV and 3D RV of the left common iliac vein and had surgery in our institution. The presence, anatomical location, and size of the venous narrowing were assessed. Stenosis was defined as luminal narrowing of 50% or more compared with the prestenotic or poststenotic lumen by visual assessment. A measured pressure gradient of 2 mm Hg or more at surgery was considered a positive result. The diagnostic accuracy was higher for the 3D images (88.2%) than for the 2D images alone (70.6%). 3D images provided higher sensitivity (90%) than the 2D images alone (66.7%). The 2D images alone had excellent specificity (100%) and positive predictive value (100%) in the diagnosis of venous narrowing. 2D DSV images provide specificity in diagnosis of venous stenosis of the left iliac vein in patients with chronic lower limb edema. In patients with negative 2D images, additional 3D RV leads to higher diagnostic sensitivity, thereby providing a powerful tool for planning surgical and endovascular treatment.