Peripheral arterial disease is highly prevalent and is characterized by a high risk of major adverse cardiovascular events and, in the stage of critical limb threatening ischemia, of major adverse limb events. A rational, stepwise diagnostic algorithm based on assessment of arterial hemodynamics avoids unnecessary imaging studies, which in most cases play a role only in the planning of revascularization procedures. In recent years, significant progress has been made in medical therapy (e.g., LDL cholesterol lowering drugs, antithrombotic treatment regimens) and endovascular techniques. A recently published randomized trial supports the clinical value of bypass surgery in critical limb threatening ischemia.