LAUSR

If patients with ominous symptoms of either ischemic rest pain, tissue loss, or gangrene are left untreated, then onequarter of these patients will lose their leg and another quarter will die within 6 months.1 This is the natural history of chronic limb-threatening ischemia (CLTI); a condition that is more fatal than most known malignant neoplasms.2 Accordingly, all societal guidelines give a class I recommendation for lower extremity revascularization for these patients.1,3,4 This can be challenging and requires addressing severe multilevel disease, including heavily calcified infrapopliteal and inframalleolar arteries, which tend to be small with long and totally occlusive lesions. Since Drs Dotter and Judkins’s 1964 experimental percutaneous transluminal angioplasty (PTA) of the superficial femoral artery (SFA) to save a patient’s ischemic limb, there has been enormous progress in the endovascular tools and revascularization techniques.5 These advances led to the doubling of endovascular revascularizations in the United States between 2003 and 2011, paralleled by a persistent decline in the rates of major amputation and in-hospital death.6