Objective This study aimed to compare the primary iliac reconstruction coupled with angioplasty of profunda femoris artery (PFA) and the primary iliac reconstruction coupled with angioplasty of superficial femoral artery (SFA) for the treatment of severe lower extremity ischemia in the elderly in the aspects of clinical data and efficacy. Methods The clinical data were reviewed of 64 elderly patients with severe lower extremity ischemia treated at Heilongjiang Provincial Hospital and First Affiliated Hospital of Heilongjiang University of Traditional Chinese Medicine from January 2016 to December 2016. They were divided into 2 groups:SFA group and PFA group with 32 patients each. The two groups were compared in ankle brachial index (ABI) before and after treatment, complication rate, mortality, operation time, hospitalization days and days of ulcer healing. SPSS statistics 17.0 was used for data analysis, and Student′s t test or Chi-square test for different data types. Results ABI indicated significant increases of revascularization in both groups after treatment (P<0.05), with SFA group being obviously greater than the PFA group (P<0.05). SFA group had fewer ulcer healing days than the PFA group (P<0.001). PFA group outperformed SFA group in complication rate (62.5% vs 12.5%), operation time [(189±41) vs(130±61)min] and hospitalization days [(18±4) vs(10±4)d, P<0.001]. No significant differences was observed in the numbers of patients with claudication of less than 100 m (50.0% vs 46.9%) and amputation (28.1% vs 25.0%) within 1 year after operation (P>0.05). Conclusion The primary iliac artery reconstruction coupled with PFA angioplasty can not only alleviate lower extremity ischemia but also significantly reduce the postoperative complications and amputation rate with increased survival rate and improved life quality of the patients.