Atherosclerotic occlusive disease of the lower extremity in patients exhibiting severe rest pain, ulceration, or tissue necrosis represents a serious threat to extremities. In the past two decades the surgical approach in the treatment of lower extremity ischemia has changed significantly due to better understanding of segmental disease and infrapopliteal disease. Also, better visualization of leg and foot arteries due to improved angiographic and surgical techniques aided by magnification have all significantly contributed to increased limb salvage. Vein, when available, is the ideal graft material both for supra and infrapopliteal reconstruction. Availability of vein as a conduit can be increased when ectopic veins such as cephalic etc., are used and also when short segments of veins are used with unconventional distal inflow sites such as SFA, distal deep femoral artery, and popliteal artery. However, when vein is unavailable, PTFE graft is a good option particularly in patients with life expectancy of less than three years. Better understanding of graft failure has lead to better graft surveillance with PVR, ABI and Duplex scanning. Timely intervention with either PTA or surgery has lead to better secondary patency of grafts. Veith et al. looked at amputation rates during the period of changing therapeutic approach and found both a decrease in primary and secondary amputation rate implying the effectiveness of an aggressive therapeutic approach. Not all aspects of lower extremity disease are understood. However, infrapopliteal disease has now been addressed and new, innovative therapeutic approaches have made significant advances in limb salvage.