This review summarizes new developments in revascularization and advanced techniques to treat lesions below the knee (BTK). The primary goal of endovascular therapy is the re-establishment of pulsatile, straight-line flow to the foot. This treatment results in relieving ischemic pain, healing of (neuro)ischemic ulcers, preventing limb loss, improving quality of life and potentially prolong survival. Balloon angioplasty is the currently established therapy, bare-metal stents are reserved for failed percutaneous transluminal angioplasty (PTA). Novel devices such as laser, excisional and rotational atherectomy systems, drug eluting stents or drug coated balloons still lack data demonstrating improved efficacy compared to conventional balloon angioplasty. The typical patient group of complex below-the-knee lesions represents an increasing population due to the increasing prevalence of diabetes and end-stage renal failure. Excellent acute technical success rates above 90%, a low frequency of complications, and high limb salvage rate of about 95% even in patients with long segment and diffuse disease seem to justify a more widespread use of endovascular therapy in tibial arteries. However, the current results of balloon angioplasty studies show a 1-year restenosis rate between 30% for short stenoses treatment and up to 80% following recanalization of an occlusion.