Over the last 3 years angioscopic techniques have been used to guide intraluminal instrumentation in 73 patients undergoing thrombectomy, nine patients with vascular trauma, and 32 patients during laser angioplasty and balloon dilation. After balloon-catheter thromboembolectomy residual, occlusive thrombi tightly adherent to the arterial wall were removed with flexible biopsy forceps in 13 of 73 (18%) patients; underlying intimal flaps were removed in another four. In nine patients traumatic intimal defects caused by iatrogenic cannulation injuries (n = 5) or external trauma (n = 4) were managed by thrombectomy followed by complete or partial intravascular removal of the intimal flap (n = 6) or dissection plane (n = 3) with long flexible forceps and rotating brushes. Traumatic intimal defects observed in two additional patients were judged to be too severe for endoscopic manipulation and required immediate bypass grafting. Inspection after angioplasty in 32 patients revealed wall charring and obvious thermal damage after laser procedures in 28 (87%) and plaque cracking, intimal flaps, and fragmentation in 26 (81%). These defects were underestimated on intraoperative angiography. Large flaps and thrombus were removed endoscopically in three. We conclude that angioscopic study reveals the extent of intimal injury and gives insights into mechanisms of instrumentation. Adherent thrombus after embolectomy by balloon catheter and intimal flaps caused by trauma or angioplasty are common and, if severe, can be successfully treated by endoscopic intravascular manipulation in selected patients.