We present our experience with a technique of endarterectomy for use in patients with iliofemoral occlusive disease, in which the atheromatous plug is extruded from the intact artery by external manipulation (pulsion). A retrospective review of consecutive patients who underwent surgical iliofemoral pulsion endarterectomy (IFPE) in two vascular surgery units between 1998 and 2006 was performed. Primary and secondary graft patency, limb salvage, and patient survival rates were determined using Kaplan-Meier methods. Fifty-eight IFPEs were carried out successfully on 54 patients (36 men, 18 women, median age 66 years) presenting with critical limb ischemia (n=23), with claudication (n=29), or in conjunction with abdominal aortic aneurysm repair (n=6). Mean (range) follow-up was 17 months (1-69). During this period six patients (all male, mean age 64 years) underwent iliofemoral bypass using a prosthetic graft when the iliac arteries were found unsuitable for endarterectomy because of hypoplasia or heavy calcification. Two-year cumulative primary patency of IFPE was 95%, secondary patency 100%, limb salvage 98.5%, and patient survival 73%. This modification of iliac endarterectomy is a relatively simple and safe technique that eschews prosthetics and offers a durable solution for the majority of patients with extensive iliofemoral occlusive disease.