Drug-eluting stents in the below-knee circulation for patients with critical limb ischemia: When and where

Critical limb ischemia (CLI) is a challenging disease that carries a grim prognosis; limb loss is a frequent occurrence that drastically affects patient mobility and quality of life. The management of this disease in the below-knee circulation is changing rapidly. The frequently encountered technical challenges, long lesions, total occlusions, dense calcifications, are being overcome by increased operator experience and improved technology. A decade ago, balloon angioplasty was the mainstay of treatment, currently, bare-metal stents, drug-eluting stents (DESs), atherectomy devices, and cryoplasty have been explored with varying degrees of success. Over the past few years, DESs in the infrapopliteal vessels have shown promising results. Several prospective randomized studies have been completed, which compare the use of DESs with bare-metal stents or balloon angioplasty for CLI with infrapopliteal disease. This article focuses on the recent evidence-based advances supporting a wider use of DESs in patients with CLI and infrapopliteal disease. The use of DESs in routine and challenging clinical scenarios is also discussed.