Limb threatening ischemia is a challenge for the vascular surgeon. Recent progress in revascularization procedures allow to minimize the primary amputation rate in the management of chronic critical limb ischemia. The authors discuss the prevalence and causes of chronic critical limb ischemia, with a special interest for diabetic arteriopathy. The technique of crural and pedal vessel revascularization is described, as well as the innovative tourniquet technique for distal bypass surgery. A review of published series of infrapopliteal bypass surgery is made. The experience of the authors during last decade with crural and pedal bypass surgery is analyzed.