The pathogenesis of foot ulceration in patients with diabetes involves the interplay of neuropathy, vasculopathy, and immune dysfunction. Autonomic neuropathy results in loss of pain sensation, decreased sweating, and the development of brittle skin, which predisposes these patients to foot trauma. As a result, the traumatized tissue progresses to necrosis and subsequent ulceration. Once an ulcer is present, the vascular supply to the foot plays an integral role in healing. Foot ischemia in patients with diabetes may be attributed to atherosclerotic macrovascular disease and additional microcirculatory dysfunction. The following report will review the role of open bypass surgery addressing macrovascular problems for limb salvage.