The management of severe critical limb ischemia in diabetics remains a major surgical challenge in the vascular fields. As the prevalence of diabetes, chronic renal insufficiency, and high risk patients increase, most patients with critical limb ischemia have popliteal/tibial occlusions requiring below-the-knee bypass grafting or intervention. Bypass surgery with vein to crural or pedal arteries remains the gold standard of revascularization, but may be limited by patients’ risk, conduit availability, and a suitable lesion, particularly when there is no extensive tissue loss in the foot. However, restenosis rates after endovascular intervention in these vessels are high, and recent advances in drug eluting balloons and stents may have promise but remain largely unproven. There is limited high-quality evidence to support treatment choices in this arena, with only one randomized clinical trial to date. The available data suggest that patients with life expectancy of at least 2 years and more extensive disease have superior outcomes with open revascularization. A selective revascularization strategy is advocated, however, endovascular therapies have an important role in current practice, which will increase further if restenosis can be overcome. Vascular surgeons or specialists should understand and be able to apply both types of revascularization modalities to optimize patient outcomes.