It has become a tradition to dedicate a spring issue of Endovascular Today to below-the-knee (BTK) interventions and critical limb ischemia (CLI). The community of medical professionals working to improve and prolong the lives of patients with this severity of peripheral artery disease continues to grow and reach for greater heights. However, as we all know, over the past 3 to 4 months, the COVID-19 pandemic has disrupted life in general and health care systems around the world. This unprecedented scenario has posed particular challenges in our most vulnerable populations, including those with CLI.

Initially, this edition was designed to focus entirely on various aspects of CLI in a conventional sense, but in light of the pandemic, specific attention is also given to its consequences on the treatment of patients with lower extremity disease. Our feature begins with a roundtable discussion featuring Sharif Ellozy, MD; Katherine Gallagher, MD; William A. Gray, MD; Zola N’Dandu, MD; Richard F. Neville, MD; Kumar Madassery, MD; and Lorenzo Patrone, MD. They discuss how their lower extremity practices have responded to ensure optimal patient care, the safety of patients and staff alike, and the potential landscape after restrictions are lifted.

A European perspective on ambulatory CLI therapy is provided by Jos C. van den Berg, MD. In the COVID-19 era, ambulatory treatment can offer a potential benefit for patients, especially in office-based labs (OBLs). These OBLs may be perceived by some patients as a safer environment than the hospital setting, and OBLs typically do not put a burden on hospital beds that are scarce and valuable in this period. An update on the role of lower extremity bypass in the management of CLI is given by Michael H. Parker, MD; Dayle K. Colpitts, DO; and Dr. Neville. Bypass surgery remains an important topic even in the era of a high patient and physician preference for endovascular therapy.

A common problem encountered in daily practices is how to manage patients with Rutherford classification 5-6 disease requiring repeat revascularization. The decision as to whether or not a point of no return has been passed will be discussed by Venita Chandra, MD, and Sabine Steiner, MD. Next, BTK chronic total occlusion crossing strategies that are commonly used in CLI patients are explained by Marianne Brodmann, MD, and Luis Mariano Palena, MD.

Despite all the progress in the development of endovascular technologies, there are still several unmet needs when performing revascularization procedures for CLI. J.A. Mustapha, MD; Fadi Saab, MD; and Sara Finton, BSN, provide a look at recently approved devices and those potentially on the way. To conclude this issue, Drs. van den Berg, Mustapha, and Neville give an update on behalf of the CLI Global Society (CLIGS), providing insights into the goals and activities of this interdisciplinary society in the recent past and in the near future. A recent webinar (organized by the CLIGS) that discussed the COVID pandemic and the impact on the treatment of patients with CLI made it clear that all efforts to save limbs and lives need to continue even in these difficult times.

Providing information to patients with CLI is perhaps even more important now than ever before. During the initial months of the pandemic, there is increasing concern for limb loss in patients due to fear of contracting the virus when seeking CLI treatment. Just as science is on its way to battle COVID-19, we must continue to fight CLI. We are deeply grateful to the colleagues who have contributed to this edition for the time dedicated to their contributions while facing increased stress and workloads related to the unprecedented health care crisis that we all are experiencing. We wish you all continued health.

Stay safe,

Jos C. van den Berg, MD, PhD
Jihad A. Mustapha, MD
Richard F. Neville, MD
Guest Chief Medical Editors