This chapter discusses the evolution of endovascular therapy. The evolution of endovascular surgery began when John Alfonso Cid dos Santos, a young physician from Portugal, improved existing radiographic techniques and applied them to imaging of blood vessels. The dawn of the endovascular era began in the 1960’s when Dr. Charles Dotter initiated a therapeutic endovascular arterial intervention by dilating an iliac stenosis with concentric flexible dilators. The 1990’s produced a paradigm shift in the management of the peripheral arterial disease. The paradigm change in the management of vascular diseases resulted in the shift in therapy from either conservative or open surgery to an “endovascular intervention first” philosophy. The justification for the treatment of paradigms centred is the advertised benefits of endovascular therapy.