Progressive peripheral artery disease, especially in the tibial and pedal vessels, can severely limit the interventions that vascular surgeons and interventionalists can provide to patients. End-stage peripheral arterial disease is often described as a disease where there are no distal targets available in the foot. Traditionally, amputation has been the only option for these patients. However with advancements in surgical and endovascular technology, surgical and now peripheral deep vein arterialization (pDVA) can be utilized. In pDVA, an arteriovenous channel is created between a tibial artery and vein and reinforced with covered stent grafts in order to increase distal limb perfusion and improve amputation-free survival. Many techniques have been described, but currently the only formal device marketed and under investigation for pDVA is the LimFlow System (LimFlow SA, Paris, France). Our institution has performed pDVA for multiple vascular patients with no other available surgical interventions. We describe the technique, postoperative care, and outcomes for these patients. Additionally, we will explore updated outcomes and applicability of the LimFlow System in the current vascular practice today.