Attempting mini-invasiveness in the critically ill patient. The endovascular first act: the below-the-knee challenges

Arterial revascularization is the first-line treatment to restore blood flow into the foot and thus prevent amputation in (chronic limb ischemia) CLI patients. The primary objectives in the treatment of CLI are to relieve ischemic resting limb pain, heal ischemic ulceration, and prevent amputation. To that end, revascularization for CLI receives a Class I recommendation from all cardiovascular and vascular surgery societies. However, selection of a revascularization method, i.e. endovascular therapy (EVT) or surgery, for the first treatment of PAD patients presenting with CLI is still controversial and its depending on the district affected by the main lesion. Moreover, revascularization strategy selection may be biased to one with which an operator is familiar. Moreover, in the past few years, new procedures and materials have been introduced in endovascular techniques together with a multidisciplinary strategy of wound care that have improved the technical success of below-the-knee (BTK) angioplasty. In addition, the concept of angiosome-directed revascularization has recently become a popular strategy of reperfusion, whereby anatomically directed arterial flow is restored straight to the wound area. This review will briefly summarize guidelines recommendation for CLI treatment, highlighting advancements in CLI management including the clinical relevance of angiosome-directed foot revascularization, and summarizing the most relevant technical aspects of endovascular revascularization and material to utilize in the BTK district.