Other endovascular methods of treating the diabetic foot

Critical limb ischemia (CLI) is an endstage manifestation of peripheral artery disease (PAD) and typically describes patients with ischemic rest pain (Rutherford Category 4), or patients with ischemic skin lesions, either ulcers or gangrene (Rutherford Category 5-6). CLI due to infrapopliteal lesions is often not a good indication for infrageniculate bypass surgery placement, due to the presence of prohibitive comorbidities, inadequate conduit, and lack of suitable distal targets for revascularization. Therefore, CLI patients due to blockage of below-the-knee arteries are in benefit of the endovascular approach. Infrapopliteal PTA became feasible with the introduction of low-profile peripheral balloon systems and the use of coronary balloons. Stent implantation, however, is generally reserved for cases with a suboptimal outcome after PTA (i.e. >50% residual stenosis, flow-limiting dissection). Because of the fear that early thrombosis and late luminal loss due to intimal hyperplasia formation will potentially lead to insufficient long-term patency rates, efforts to extend the range of endovascular approaches to CLI are presently focused on. Cryoplasty, scoring balloon angioplasty, excimer laser therapy and atherectomy using different types of atherectomy devices have been introduced. The current article provides an overview of the endovascular treatment strategies for infrapopliteal lesions in patients with CLI.