Chronic limb-threatening ischemia represents the most severe form of peripheral artery disease and is associated with high risks of limb loss and mortality. It is closely associated with below-the-knee arterial disease, with substantial overlap between the two conditions, particularly in patients with diabetes. Endovascular treatment plays a central role in restoring distal tibial and pedal perfusion, which is critical for wound healing and limb salvage. However, it remains technically challenging due to small vessel size, diffuse disease, and heavy calcification, which limit luminal expansion and predispose to recoil, dissection, and restenosis. Procedural success requires a structured approach integrating access strategy, guidewire crossing, and subsequent treatment. Crossing strategies, including subintimal tracking, retrograde tibio-pedal access, and bidirectional techniques such as controlled antegrade and retrograde tracking, are often required in complex lesions. Plain balloon angioplasty remains the most broadly applicable treatment, whereas drug-coated balloons show inconsistent benefit. Drug-eluting stents provide favorable outcomes in selected short focal lesions, whereas other technologies have more limited evidence. Overall, treatment should be individualized based on lesion characteristics and clinical context.