Endovascular interventions have gained widespread acceptance as primary and secondary treatments for critical lower extremity ischemia (CLI), and many believe there is little need for open bypasses for CLI. Despite this, some patients presenting with CLI require traditional lower extremity bypass procedures at some point for successful limb salvage. To determine the proportion of patients requiring an open procedure, we reviewed our 1-year experience with CLI patients at a center committed to endovascular approaches whenever possible. We reviewed all patients presenting with CLI from January 1, 2007 to December 31, 2007. CLI was defined as ischemic rest pain, nonhealing ulceration, or gangrene for which a major amputation was imminently required. All patients underwent duplex and conventional angiography before intervention. Endovascular treatments were favored as primary, secondary, or tertiary treatments, if possible. If these failed or were impossible, standard lower extremity bypasses were performed. One hundred and forty-eight patients presented with primary, secondary, or tertiary CLI over this 1-year period. Of these, 63 (42%) were treated successfully with an endovascular intervention, and 69 (47%) required standard lower extremity bypass, and 16 (11%) required a combined endovascular and open procedure (i.e., hybrid procedure). Of these 148 patients, 46 (31%) were presenting with secondary, tertiary, or more CLI after failed previous (1-5) procedures. Despite the initial enthusiasm that the majority of patients presenting with CLI may be treated with endovascular procedures, there exists a significant cohort of patients that will ultimately require standard open surgical procedures.