Beyond the pedal-plantar loop: alternative inframalleolar endovascular routes for lower limb angioplasty

Revascularisation angioplasty plays a key role in the management of chronic limb-threatening ischaemia. Over the past two decades, the pedal-plantar loop has emerged as the primary inframalleolar anastomosis for endovascular treatment with promising outcome data for wound healing, limb salvage, and overall survival. This review highlights alternative anastomoses that can serve as targets for angioplasty and routes for retrograde wiring when the pedal-plantar loop is absent or impassable. Each alternative anastomosis is described with key anatomical landmarks, schematic diagrams, imaging examples, and practical considerations. Recognising these vascular variations and their radiographic landmarks enhances the effectiveness of endovascular interventions, providing additional conduits in cases of difficult occlusions or anatomical variants.