Although peripheral arterial disease is prevalent in patients with renal insufficiency, little is known about how the disease is managed in this patient group. The management of advanced limb ischemia was examined in a large cohort of male veterans (n = 6227). Patients were classified according to whether they underwent lower extremity revascularization, amputation, or no procedure within the first 6 mo after their first diagnosis of critical limb ischemia, defined as ischemic rest pain, ulceration, or gangrene. The association of renal insufficiency with revascularization and the association of management strategy with mortality within 1 yr of cohort entry were measured. Within 6 mo of initial diagnosis of critical limb ischemia, 39% of patients underwent lower extremity revascularization, 27% underwent major amputation, and 34% did not undergo either procedure. Patients with an estimated GFR 30 to 59 (adjusted odds ratio [OR] 0.84; 95% confidence interval [CI] 0.72 to 0.96), 15 to 29 ml/min per 1.73 m2 (OR 0.47; 95% CI 0.35 to 0.65), 15 ml/min per 1.73 m2 not on dialysis (OR 0.32; 95% CI 0.16 to 0.62), and dialysis patients (OR 0.62; 95% CI 0.47 to 0.84) were less likely to undergo revascularization than those with an estimated GFR > or = 60 ml/min per 1.73 m2. At all levels of renal function, mortality risk was lowest for patients who underwent revascularization. Patients with critical limb ischemia and concomitant renal insufficiency are less likely to be treated with revascularization. However, among patients with renal insufficiency, mortality is lowest for patients who receive a revascularization. Further studies are needed to determine the optimal care for this high-risk patient group.