Endovascular and open surgical techniques form a spectrum of options for the optimal, current treatment of aortoiliac occlusive disease. The results of endovascular intervention are determined primarily by lesion characteristics and the associated pattern of occlusive disease while the results of open vascular surgery are more significantly influenced by the patients' comorbid conditions and surgical risk. Categorizing lesions according to severity enhances appropriate patient selection. The long-term success is higher with open surgery while the initial morbidity is lower with endovascular techniques. Open surgery is a better choice for patients with extensive occlusive disease and/or less severe comorbid conditions. Endovascular surgery is not as durable but offers a reasonable option for patients with focal disease and/or contraindications to surgery.