Acute leg ischemia arguably is the most challenging condition that a vascular surgeon has to manage. Patients have widely different presentations, there are several available treatment options, and, yet, despite best efforts, the outcome remains poor. An understanding of the changes in population demographics in affluent western societies, set in an historical context, enables choices about therapy. A vascular unit serving a community including half a million people can expect to treat approximately 75 patients with acute leg ischemia per year. It is vital that a team approach is used to decide management because endovascular treatment with peripheral thrombolysis is increasingly important. The distinction between etiology of thrombosis or embolism remains important, although the diagnosis can never be conclusive. The severity of arterial ischemia is a more important determinant of outcome; optimal management, therefore, begins with stratification according to the severity of ischemia on admission to the hospital. Subsequent care lends itself to organization by care-pathway or guidelines that take into account the available local facilities.