Endovascular interventions enable a minimally invasive approach to a variety of cardiovascular lesions. Small catheter-based delivery systems have rapidly evolved, diversifying endovascular therapeutic options. Coronary and peripheral vascular occlusive lesions may be amenable to angioplasty dilatation, intravascular stenting and ablation with mechanical atherectomy devices or lasers. New experimental transluminally placed endovascular stented grafts (TPEGs) have demonstrated feasibility for treating aneurysmal arteries, arteriovenous fistulas, and atherosclerotic occlusions. Improvements in imaging systems have provided better resolution of lesions, have improved patient selection and interventional strategy, and are invaluable for precise performance of procedures. The ideal guidance system should provide realtime imaging by a combination of complimentary modalities. These include cinefluoroscopy and contrast angiography, catheter-based intravascular ultrasound and angioscopy.