Background: The development of subintimal angioplasty offers an endovascular approach to the treatment of long occlusions not suitable for conventional transluminal angioplasty; it remains, however, the remit of relatively few radiologists in specialist centres. The authors have adopted the technique in view of promising published results. Methods: Between May 1997 and July 2000, 50 patients had attempted subintimal angioplasty (median age 71 (interquartile range (i.q.r.) 61–80) years). Patients were divided into two groups by length of occlusion; 26 patients (group 1) had occlusions greater than 10 cm in length (iliac, one; superficial femory artery (SFA), 24; crural, one) and 24 patients (group 2) had occlusions of less than 10 cm (iliac, five; SFA, five; popliteal, nine; crural, five). The primary technical success rate, ankle: brachial pressure index (ABPI) before and after the procedure, complication rate and symptomatic improvement were recorded for both groups. Results: The groups were well matched for age and indication for intervention. Primary technical success was significantly better for occlusions of less than 10 cm than for the longer lesions (83 versus 50 per cent; P < 0·01) with corresponding significantly greater rises in ABPI (P < 0·05). Complications included one death in each group, one amputation in group 2 and six in group 1, all after failed salvage grafts. Group 1 (> 10 cm) Group 2 (< 10 cm) P Technical success13 of 2620 of 24>0·01*Median (i.q.r.) ABPI change0·135 (−0·07 to 0ë23)0·24 (0·145–0·355)0·046† Conclusion: Subintimal angioplasty gives excellent results for occlusions of less than 10 cm in length irrespective of arterial site. Results for longer lesions are poor, with failed subintimal angioplasty often precipitating urgent distal vascular reconstruction and associated high risk of major amputation. © 2001 British Journal of Surgery Society Ltd