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Chronic limb-threatening ischemia (CLTI) carries a significant risk of limb loss and thus demands urgent attention. Calcified atherosclerotic disease affecting the infra-popliteal (IP) arteries poses a formidable challenge for effective revascularization due to the narrow vessel diameter and the common presence of extensively calcified, long occlusive lesions. Intravascular lithotripsy (IVL) is an endovascular treatment that induces microfractures in the medial calcifications of blood vessels, thereby facilitating the clearance of calcified obstructive arterial lesions. This review assesses the growing body of evidence from multiple prospective studies that have investigated the role of IVL in the treatment of peripheral arterial disease (PAD) involving the IP segment. The clinical efficacy of IVL has been extensively studied and validated in various trials and real-world experiences. These studies consistently demonstrate IVL's ability to achieve vessel preparation, with excellent procedural success rates and low rates of major adverse events. Moreover, IVL has shown remarkable versatility, proving effective across a wide spectrum of PAD, including iliac artery disease, femoropopliteal disease and IP calcified disease. The available results from existing literature are encouraging and demonstrates safety and efficacy of the technology in treating calcified PAD. Additional studies on a larger scale are needed to better understand its long-term effects.

Background: The superiority of drug eluting stents versus bare metal stents or balloon angioplasty in the treatment of patients with critical limb ischemia and infrapopliteal lesions has been established. However, only shorter lesions were evaluated. This study was designed to evaluate the immediate and long-term (up to 12 months) outcome of the Xience Prime™ Everolimus-Eluting Coronary Stent System (Abbott Vascular) in a controlled, prospective, multi-center investigation for long lesions up to 10 cm., Methods: All patients with critical limb ischemia and long infrapopliteal lesions between 30 and 100 mm, who met the inclusion criteria, were included in this study. The primary endpoint was primary patency at 12 months, defined as absence of restenosis (≥50% stenosis) or occlusion based on quantitative analysis of contrast angiography., Results: Between August 2011 and October 2013, 60 patients were enrolled in this study with a mean lesion length of 47.40±25.06 mm (range 2-100 mm). The primary patency rate at 12 months was 75.4%. Freedom from target lesion revascularization was 84.9%. The amputation rate was rare (94.4% freedom from amputation). At the 12-month follow-up time point, a total of 36 out of 42 (85.7%) patients improved in their Rutherford classification by at least 1 class., Conclusions: The use of everolimus-eluting stents in longer infrapopliteal lesions in the treatment of critical limb ischemia is safe and effective with a comparable primary patency, freedom from target lesion revascularization and amputation free survival as in short lesions.

The popliteal artery (PA) may well be the most challenging of all infra-inguinal vessels to treat. Not only is it anatomically unique but it's also exposed to some of the most brutal forces seen in the lower limb, during normal knee flexion. Management may be challenging and with few randomized trials dedicated to answering questions of technical success and durability the correct approach remains contentious. Herein we seek to describe and evaluate the growing number of options for treatment in this vascular territory.

The use of endovascular techniques for the treatment of occlusive arterial disease below the knee has gained widespread acceptance and is considered by many as the first line treatment for patients with critical limb ischaemia. Tibial angioplasty and stenting have a high rate of technical success and are relatively low risk procedures, which has widened their applicability to include treatment for the elderly and those with comorbidities unsuitable for open bypass surgery. Despite these advantages the durability of the percutaneous revascularisation remains inferior to that of open surgery for diffusely diseased arteries. In the search to improve their long term performance we have sought to investigate the role of coronary drug eluting stents (DES) in the tibial vasculature in the hope that they may reduce recurrent stenosis, the leading threat to interventional patency. Ample data now exists in the form of registries and randomised trials designed to evaluate the use of DES in the crural arteries below the knee. This article reviews this body of research, explores the use of these devices in more complex lesions, speculates on their future development and examines their cost-effectiveness.

The treatment of peripheral arterial occlusive disease with endovascular therapy is rapidly becoming the standard of care. Akin to the movement towards percutaneous coronary interventions that occurred with gusto throughout the 1980s and 1990 s, treatment for the peripheral vasculature has undergone its own paradigm shift. Such that many feel that a first-line catheter-based approach is justified for the majority of patients in 2012. Extensive occlusive disease of the aorto-iliac segment is an area where open surgery has historically been preferred over endovascular therapy. This is partly because the open surgical standard of aorto-bi-femoral bypass has durability unrivalled by other forms of peripheral revascularisation surgery. Furthermore, some have avoided endovascular interventions in this region because of fears of perforation, bleeding and limited technical success in an area where the blood vessels carry a heavy burden of disease and a large thrombotic load. Throughout surgical history we have seen advances in technology emerge to provide a medium through which the proceduralist may extend their indications for treatment. A number of re-entry devices which provide a reliable method of wire passage beyond chronic occlusions of the aorta and iliac arteries have emerged and for the first time are safely facilitating high technical success rates in the treatment of aorto-iliac occlusive disease (AIOD). What follows is a summary of both open and endovascular treatment options for AIOD. Moreover, this review will provide an evidence based description of the emerging litany of devices which aid in wire passage through this most challenging of vascular territories.