A complete discussion of ongoing technical advances and novel devices is beyond the scope of the toolkit. Nevertheless, a select set of concepts are deserving of mention, as they have penetrated current practice but continue to stimulate discussion and controversy.
Alternative/Retrograde Pedal Access: Achieving straightline flow to the foot and direct revascularization to the angiosome of interest can be challenging. Advanced revascularization techniques are being incorporated by many CLI centers worldwide. Obtaining retrograde arterial access from the dorsalis pedis artery or distal posterior tibial artery may facilitate crossing of complex infrapopliteal artery disease.
Pedal Loop Technique: Similarly, pedal arch patency has been associated with worse outcomes. Pedal arch intervention with so-called, “pedal loop” technique is being used by many with the hope of improving patency, perfusion, and wound healing. Patients undergoing such methods of revascularization are frequently medically complex and without alternative options. As such, high-quality randomized data for such techniques have been difficult to produce.
Common Femoral Artery Intervention: Anatomic regions considered to be under extreme flexion, such as the common femoral artery and popliteal artery, were “no stent zones”. However, novel devices and recent data have rendered common femoral artery intervention less anathema. Recently, 117 patients with isolated common femoral artery disease were randomized to either common femoral endarterectomy or percutaneous revascularization. After 24 months, no significant differences were seen in primary patency rate, target lesion revascularization rate, or sustained clinical benefit (33).