Patients with multilevel atherosclerotic disease represent a difficult surgical challenge. In the 5 decades that have relapsed since the introduction of initial methods of revascularization, a wide variety of the therapeutic options have been developed and advocated for management of aortoiliac disease. With the aid of dramatic advance of endovasular technique, various nonoperative catheter based endoluminal therapies have been accentuated in recent years by the explosive growth in vascular surgical procedures. A combination of iliac PTA and distal surgical revascularization would appeal to be a logical and potentially advantageous methods of revascularization in selected patients. This report is a retrospective review of 20 patients who were treated using a combination of lilac transluminal angioplasty and/or stent and infrainguinal reconstruction. They were 19 males and 1 female with an average of 69 years (range : 48 to 74 years). Follow-up period ranged from 1 month to 92 months( median : 28 months). These patients had cormorbid disease including heart disease (35%), hypertension(35%), diabetes mellitus(15%), hyperlipidemia(15%); 90% of the patients were smokers. Ten patients were treated for rest pain or tissue loss, while ten were treated for moderate or severe claudication. Distal operation included 7 femorofemoral bypass, 11 femoropopliteal(AK) bypass, 4 femoropopliteal(BK) bypass, 1 pop-tibial bypass. A mean resting iliac artery pressure gradient of 27.6+/-22.8 mmHg pre-PTA was reduced to 3.1+/-4.3 post PTA. Mean pretreatment ankle/brachial index of 0.36+/-0.28 increased to 0.80+/-0.16 after operation(P<.001). By Kaplan-Meier method, the 5-year primary patency rate of the distal surgical procedures was 72%. The procedures were well tolerated with no mortality and two complication occurred, but all were sucessfully corrected by stent insertion for intimal dissection and Urokinase infusion for thrombosis. Two patients underwent amputation due to preoperative wide skin ulcer and knee joint infection. We conclude that in selected patients, combined use of iliac PTA or stent insertion and distal surgical reconstructions is safe and effective modality for managing the patients with severe multilevel occlusive disease.