It is our privilege to introduce this issue of Endovascular Today dedicated to the management of patients with critical limb ischemia (CLI). We have now arrived at our fourth edition collaborating as Guest Chief Medical Editors of this issue, owing to a great history of collaboration with Endovascular Today that started in 2015. Looking back at previous CLI issues, we can see a clear evolution in the way we view this disease, with an increasing emphasis on employing a multidisciplinary, multimodality approach.

No catheter-based therapy can be delivered without first getting past the occlusive lesion, and crossing tools and algorithms are therefore extremely important in optimizing technical success rates. Crossing tips and device selection are discussed by Osamu Iida, MD; Yosuke Hata, MD; and Toshiaki Mano, MD.

Next, Fadi Saab, MD, and Dr. Mustapha present an analysis of why antegrade procedures fail and how the desire to improve technical outcomes led to the development of an algorithm to provide guidance for selecting the optimal crossing approach for chronic total occlusions (antegrade or retrograde).

There has been a lot of discussion over the last few years regarding the angiosome concept. Our increasing knowledge about the angiosome concept, which was developed in healthy subjects, has evolved to a more sophisticated and reality-based “angiographosome” concept, as described by Chris Shackles, DO; Kevin “Chaim” Herman, MD; Vincent Gallo, MD; and John H. Rundback, MD.

Once a lesion has been crossed and treated, we are oftentimes faced with the dilemma of whether additional revascularization is needed. Miguel Montero- Baker, MD; Arne Schwindt, MD; and Theodosios Bisdas, MD, describe how a novel tool for perfusion measurement may help with this determination of whether further treatment is warranted.

The potential role of drug delivery devices to obtain durable results in treating below-the-knee disease is discussed by a panel of experts including Marianne Brodmann, MD; Antonio Micari, MD; Dr. Mustapha; and Ramon L. Varcoe, MBBS.

When all conventional techniques fail and amputation is imminent, there still may be a role for venous arterialization (either by surgical or endovascular means). An overview of the current status of this option is provided by Daniel A.F. van den Heuvel, MD; Michiel A. Schreve, MD; and Steven Kum, MD.

This issue highlights the fact that a basic understanding of CLI, with regard to etiology, treatment algorithms, techniques, technologies, and monitoring, is needed for the outcome we ultimately want to avoid: amputation.

We hope you enjoy reading this issue and that it will provide additional insights that will allow you to offer better care to your patients with CLI.

Jos C. van den Berg, MD, PhD
Jihad A. Mustapha, MD, FACC, FSCAI
Guest Chief Medical Editors