Tibial and Pedal Plantar Interventions in Patients with Critical Limb Ischemia

The most morbid form of peripheral arterial disease (PAD) remains critical limb ischemia (CLI) associated with rest pain, gangrene or limb loss. This chapter reviews the basic epidemiology of distal tibial and forefoot disease, outlines the indications for percutaneous therapy of this vascular territory, and explores procedural considerations for modern distal extremity endovascular interventions. Patients with history and physical exam findings concerning for CLI should generally have non-invasive testing to establish a diagnosis. The ankle-brachial index (ABI) is a simple yet powerful tool and usually the first test of choice to detect PAD. Contralateral femoral access remains the most common approach to treat infrainguinal PAD, but may have limitations when trying to treat infrapopliteal lesions. To address the limitations of percutaneous transluminal angioplasty (PTA), stenting has been employed to treat flow-limiting dissections or persistent restenosis. To combat the risk of restenosis, antineoproliferative therapy has been explored in both drug-eluting stents (DESs) and drug-eluting balloons (DEBs).