Chronic limb-threatening ischemia (CLTI) carries a poor prognosis, with revascularization aimed at healing wounds, alleviating pain, and preventing major amputation. Interventions below the knee (BTK) are complicated by inherent anatomical challenges, including small vessel caliber, complex occlusive disease, and severe calcification, which can lead to suboptimal outcomes. Percutaneous transluminal angioplasty (PTA) has long been considered the standard of care for BTK intervention but has significant limitations, including high rates of recoil, dissection, and restenosis. This presentation will discuss the evidence for emerging technologies designed to overcome these challenges, such as drug-coated balloons (DCBs), different atherectomy devices, drug-eluting stents (DES), and more recently, bioresorbable scaffolds (BRS). The discussion will review the conflicting trial data, the specific niches for each technology, and the widening gap between evidence and practice for certain devices. Ultimately, technical success does not always equate to clinical success. The optimal BTK strategy requires a sophisticated, evidence-based approach that tailors the correct technology to the specific patient and lesion anatomy within a multidisciplinary team framework. Future head-to-head trials of modern strategies and a focus on clinically important outcomes are needed to continue advancing care for this complex patient population