Purpose: The current standard of care for the treatment of flow-limiting calcific iliac artery disease is balloon angioplasty and subsequent stent placement. However, the presence of calcified lesions may prevent adequate stent expansion or impede the delivery of large-bore devices such as TAVR or EVAR implants. Plaque modification through vessel preparation with orbital atherectomy (OA) may enable stent expansion and subsequent proper large device delivery with low rates of procedural complications. Materials and Methods: A single-center retrospective study of 13 subjects (14 interventions) treated with OA via iliac artery delivery was conducted. Patients were selected for treatment based on iliac artery disease or inability to deliver devices. The procedural complication rate was defined as the composite of flow-limiting dissection, perforation, slow flow, vessel closure, spasm, embolism, thrombosis. Technical success was assessed as angiographic luminal gain and subsequent successful delivery of large-bore devices through the treatment area, as well as freedom from procedural complications. Results: The cohort was comprised of 13 patients (age 72.4 ± 10.9 years; 9 males, 4 females) with 1 lesion per vessel, an average lesion length of 34.2 ± 10.8 mm, and an average reference vessel inner diameter of 9.2 ± 0.9 mm. Lesions were located in the common iliac arteries (with some extending into the common femoral arteries). The top three associated demographic risk factors were hypertension (92%), history of smoking (85%), and diabetes mellitus (54%). The mean total treatment time using OA per patient, per lesion site in the 14 interventions was 135.3 ± 51.9 seconds. The mean maximum balloon inflation pressure per treated lesion site was 10.9 ± 6.3 atm. The procedural complication and technical success rates were 0% and 100%, respectively. Conclusions: Orbital atherectomy vessel preparation of severely calcified iliac artery lesions resulted in adequate stent expansion safely and enabled delivery of rigid/large-profile devices. Further studies are warranted to evaluate patient selection criteria, as well as long-term efficacy and safety rates.