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Critical limb ischemia (CLI) is a severe form of peripheral arterial disease (PAD) marked by ischemic rest pain, tissue loss, or gangrene. CLI is associated with significant morbidity, mortality, and resource utilization. Patients can be treated with revascularization, either surgical or endovascular. To help clinicians, patients, and policymakers decide between surgery-first and endovascular-first approaches in patients with CLI, we were asked to conduct a systematic review of the literature.