Improved appreciation and understanding of peripheral arterial disease in general and critical limb ischemia more particularly has been fostered by and has driven developments in novel techniques and technology required to treat the heterogeneous anatomic and therapeutic challenges posed by this disease. The affected patient population tends to be uniquely sick, afflicted with multiple comorbidities and at risk for severe adverse outcomes. Even so, conventional approaches involving incomplete or indirect revascularization, failure to provide timely, thorough preoperative non-invasive or angiographic evaluation and primary amputation are still widely seen in practice. Systematic application of new diagnostic and interventional techniques, new concepts in wound care and an expanded palette of wound care products have yielded significant improvements in amputation free survival and increased patient and provider satisfaction. Despite clear progress slow rates of adoption and inconsistent utilization of endovascular approaches to limb preservation have retarded the decline in major amputation rates in many areas. We can do better!