Purpose of Review <p>Patients with end-stage renal disease often suffer from advanced atherosclerotic calcifications of the aortoiliac vasculature due to hypertension, diabetes and uremia. These aortoiliac calcifications can pose a significant anatomic barrier to successful renal transplant. In this review, we discuss screening strategies for aortoiliac calcification in renal transplant candidates and several surgical approaches permitting renal transplant in the setting of severe aortoiliac disease.</p> Recent Findings <p>Techniques such as iliac endarterectomy, iliac interposition graft, end-to-side iliac extension and sewing the kidney onto an aortobifemoral bypass graft are well-described. Several newer techniques, such as use of endovascular balloons for vascular control, remote endarterectomy, physician-modified fenestrated endografts and placement of the renal allograft upside-down have also been recently described.</p> Summary <p>Innovative surgical techniques can enable successful renal transplant in patients with advanced aortoiliac calcifications that were previously deemed to have anatomic contraindications to transplant.</p>