Two decades after the clinical introduction of percutaneous transluminal angioplasty (PTA), controversy still exists about the role of PTA for the treatment of occlusive disease in the femoropopliteal and infragenicular arteries. For the patient with critical limb ischemia (CLI), where diffuse disease and long occlusions are the rule, the results with PTA have not been optimal. Surgical revascularization has long been considered the gold standard for this patient population, but this procedure is associated with significant morbidity and mortality and up to 37% of patients may be poor surgical candidates. With advances in laser catheter design and refinement of recanalization techniques, improved results have been seen with laser assisted angioplasty of complex peripheral arterial disease. There has been renewed interest in excimer laser angioplasty for the treatment of patients with long total occlusions and diffuse disease who otherwise would have limited options for treatment. Excimer laser assisted angioplasty has been shown to be a successful approach to the treatment of long occlusions in the superficial femoral artery. Data from the recently completed Laser Angioplasty for Critical Limb Ischemia Phase 2 Trial (LACI) suggest that this is a viable treatment strategy for patients with CLI who are otherwise not good candidates for bypass surgery.