The surgical management of aortoiliac atherosclerotic occlusive disease includes endarterectomy and prosthetic by-pass in either the anatomical or extraanatomical position. Aortoiliac endarterectomy is only indicated in localized disease which spares the external iliac artery and does not exhibit aneurysmal changes. Prosthetic by-pass is easier to perform, but carries graft-related risks including anastomotic pseudoaneurysms in 5 to 10% of cases at 10 years. Extraanatomical shunts are performed when there are general or abdominal contraindications to an anatomical by-pass. Simultaneous revascularisation of the aortic visceral branches mainly involves the renal, inferior mesenteric and hypogastric arteries. Correction of celiac and superior mesenteric artery stenosis is less frequently indicated. The appropriate approach and surgical technique depend on the artery and the lesion involved. Suprarenal implantation of aortoiliac by-passes is performed at the celiac, descending aortic and ascending aortic levels. Indications include suprarenal coarctation of the aorta, reoperation following ligature of the juxtarenal aorta, and some cases of extensive thoracoabdominal atherosclerosis. The surgical management of aortoiliac occlusive disease in 353 patients treated in our clinic between 1976 and 1986 is reported. Mean follow-up exceeded 5 years. Operative mortality for endarterectomy (15 patients) was nil, and was 3.9% for by-pass graft. Early complication rate was 6.5% and late complication rate 23.2%. Half of the late complications were due to progression of the atherosclerotic process. Pseudoaneurysms at the aortic (3.1%) and femoral (9.9%) levels occurred between the fifth and tenth years. Prosthesis infection occurred shortly after operation in 3 patients and much later in 2 patients.