In this critical review, we present the current technological advances in proton exchange membrane (PEM) fuel cell catalysis, with a focus on strategies for developing nanostructured Pt-alloys as electrocatalysts for the oxygen reduction reaction (ORR). The achievements are reviewed and the major challenges, including high cost, insufficient activity and low stability, are addressed and discussed. The nanostructured Pt-alloy catalysts can be grouped into different clusters: (i) Pt-alloy nanoparticles, (ii) Pt-alloy nanotextures such as Pt-skins/monolayers on top of base metals, and (iii) branched or anisotropic elongated Pt or Pt-alloy nanostructures. Although some Pt-alloy catalysts with advanced nanostructures have shown remarkable activity levels, the dissolution of metals, including Pt and alloyed base metals, in a fuel cell operating environment could cause catalyst degradation, and still remains an issue. Another concern may be low retention of the nanostructure of the active catalyst during fuel cell operation. To facilitate further efforts in new catalyst development, several research directions are also proposed in this paper (130 references).