Advanced limb salvage: Pedal artery interventions

Chronic limb-threatening ischemia (CLTI) is on the rise due to the increasing prevalence of diabetes, which is a significant cause of morbidity and mortality worldwide. Due to diabetes, many patients with CLTI present with a predominance of tibial and pedal artery disease. Despite best care, limb amputation cannot always be prevented. Surgical bypass has always been the mainstay in distal revascularization and limb salvage; however, many patients with CLTI have comorbidities, insufficient vein, and anatomic abnormalities that prevent them from undergoing surgery. As a result, endovascular therapies have increased over the last 2 decades and are providing revascularization options in these patients. Although most of the current endovascular literature has focused on above-ankle arterial interventions, recent studies have highlighted the feasibility, safety, and clinical importance of pedal artery interventions. These endovascular techniques hold promise in relieving ischemic pain, healing foot ulcers, reducing rates and extent of amputation, and improving patient functionality and quality of life. This review aims to comprehensively detail pedal artery interventions in terms of anatomy, technique, intraprocedural imaging, and outcomes. In addition, suggestions of when to perform pedal artery interventions and post-intervention surveillance options will be discussed.