Below-the-knee (BTK) artery disease is a major pathological basis for chronic limb-threatening ischemia (CLTI). In recent years, endovascular therapy has progressively emerged as a significant approach for the treatment of BTK arterial disease, with notable advancements achieved in treatment strategies, vascular preparation devices, and related techniques. The treatment strategy has evolved from “the Global Vascular Guidelines (GVG)” and “the International Working Group on the Diabetic Foot (IWGDF), the European Society for Vascular Surgery (ESVS), and the Society for Vascular Surgery (SVS) guidelines on peripheral artery disease in people with diabetes and a foot ulcer” to the “Woundosome” concept. This framework emphasizes “wound perfusion improvement” as the ultimate goal. In terms of vessel preparation devices, paclitaxel-coated balloons have demonstrated advantages in patency and limb salvage for complex lesions, while sirolimus-coated balloons show potential for a superior safety profile. Bioresorbable scaffolds offer a novel “support-then-absorb” solution. Technically, vascular preparation devices (e.g., shockwave balloon) effectively manage severe calcification, and deep venous arterialization provides a last resort for limb salvage in “no-option” patients. Future developments in this field will rely on generating higher-level clinical evidence and constructing personalized treatment pathways tailored to patient characteristics and available medical resources, aiming to continuously improve limb salvage rate and quality of life for CLTI patients.
