Background: Carbon dioxide (CO₂) has been used as an arterial contrast agent for high-risk patients who were allergic to iodinated contrast material and for those with chronic kidney disease (CKD). The feasibility, safety, imaging quality and therapeutic role of CO₂ angiography in the endovascular therapy (EVT) for patients with CKD was evaluated. Methods and Results: EVT was performed in 107 consecutive patients with iliofemoral artery disease (148 limbs; mean age, 73±9 years) who were admitted to our hospital from January 2010 to April 2011. Intravascular ultrasound (IVUS)-guided EVT with CO₂ was applied for the treatment of 50 patients (70 limbs) with CKD (group 1). IVUS-guided EVT with iodinated contrast media was applied for the treatment of 57 patients (78 limbs) without CKD (group 2). CO₂ was injected by hand using a simple homemade delivery system. The overall technical success was 100% in both groups without any major complication. Preprocedure and postprocedure ankle-brachial indices significantly improved in the both groups (0.93±0.11 vs. 0.59±0.19, P<0.01; 0.95±0.13 vs. 0.62±0.22, P<0.01, respectively). All of the CO₂ arteriograms were good or acceptable imaging quality if assessed by 2 independent observers. Conclusions: CO₂ arteriograms, using an inexpensive simple homemade delivery system, are feasible and safe in patients with CKD in the evaluation and for EVT of iliofemoral artery disease.  (Circ J 2012; 76: 1722–1728)