Endovascular therapy for infrapopliteal vascular disease is gaining acceptance as there is growing evidence demonstrating its safety and effectiveness. It is most commonly used to treat patients with chronic critical limb ischemia (CLI) for limb salvage and wound healing. Its use to treat lifestyle altering claudication remains controversial. For the treatment of CLI, limb salvage rates with infrapopliteal percutaneous transluminal angioplasty (PTA) are high enough that these techniques are offering an alternative to bypass surgery. Current patency rates from infrapopliteal PTA can be improved further by proper patient selection, ensuring straight-line flow to the foot in at least one tibial vessel, and close patient surveillance for early reintervention. Possible future advances including the use of drug-eluting stents, cutting balloons, and aggressive antiplatelet regimens are being tested to improve clinical outcomes following endovascular interventions on the tibial arteries.