With rapid advancements in noninvasive vascular imaging, the use of conventional catheter angiography for the diagnostic evaluation of diseases of the carotid and vertebral arterial vasculature has shown a steady decline over time. Cross-sectional imaging modalities and other noninvasive techniques for vascular diagnosis are less prone to some of the risks associated with the invasive nature of catheter angiography and less prone to operator techniques and experience. Certain patients with severe allergic reaction to iodinated contrast may be imaged with unenhanced MRI techniques and Doppler ultrasound. However, there remain unique situations where invasive catheter angiography can be invaluable in the evaluation of extracranial carotid and vertebral disease and can be a useful problem-solving tool. Some common indications for arteriography of the extracranial carotid and vertebral arteries include conditions such as steno-occlusive disorders commonly due to atherosclerotic vascular disease; evaluation of aneurysms and vascular malformations of the head and neck, including upper cervical spinal vascular lesions; pre-therapeutic evaluation of vascular tumors; and balloon test occlusion prior to vessel sacrifice or surgical exploration.