Background: Critical limb ischemia (CLI) represents the extreme of the peripheral arterial occlusive disease spectrum and is associated with high mortality. Limb salvage often requires infrapopliteal revascularization by either angioplasty or bypass surgery. The past decade has witnessed a paradigm shift in CLI management toward endovascular treatment. This narrative review describes the clinical outcome, treatment strategy, and limitations of both modalities. Method: A literature search was performed of the PubMed and Cochrane databases. All articles, published until September 2011, describing treatment by infrapopliteal arterial revascularization were included. Results: Angioplasty and bypass surgery are both related to a limb salvage rate of approximately 80% at 3-year follow-up. Patency rates appear to be higher after surgery. A reliable comparison of the two modalities, however, is complicated by various confounders, including patient selection, lesion characteristics, and complication rates. Additionally, most studies did not describe the standard use of best medical treatment or outcome for relief of ischemic pain, wound healing, or functional improvement. Conclusion: Infrapopliteal angioplasty and bypass surgery both provide an acceptable limb salvage rate, but patency appears to be better after bypass surgery. Both modalities are likely to be complementary. Additional randomized trials are indicated to provide a treatment algorithm for patients with CLI and infrapopliteal arterial occlusive disease.