Hemodynamic assessment of aortoiliac occlusive disease is necessary for successful arterial reconstruction of the aorta and legs. Various methods have been proposed and "pull-through" intra-arterial pressures are the "gold standard." Deep Doppler duplex imaging was supplemented with real-time spectral analysis and velocity measurements in 29 cases. Twenty-three of these patients needed arteriography. One hundred sixty-six (166) arterial segments extending from the proximal aorta to the common femoral arteries were independently graded on duplex scans and arteriograms. For severe occlusive disease, duplex scanning is highly accurate (sensitivity 82%, specificity 93%). Velocity measurements were useful in determining the hemodynamic significance of stenoses. Peak systolic velocities in stenoses were measured with a duplex scanner. The pressure gradient calculated with the modified Bernoulli equation (delta P = 4Vmax2) correlated well with the gradients measured during arteriography (r = 0.9, n = 11). These noninvasive velocity measurements and Bernoulli calculations alert arteriographers to obtain special views of suspected areas and suggest the need for "pull-through" pressures and possible balloon angioplasty. In addition, these noninvasive measurements are useful to follow up patients who have mild to moderate aortoiliac disease and after angioplasty.