Background: Diabetes mellitus is strongly associated with below-the-knee peripheral arterial disease, chronic limb-threatening ischemia, foot ulceration, infection, and major amputation. Endovascular below-the-knee intervention has become an important limb-salvage strategy.

Objective: To review indications, techniques, outcomes, limitations, and future directions of below-the-knee interventions in diabetic patients.

Methods: This narrative review summarizes contemporary evidence on tibial and pedal artery angioplasty, wound-directed revascularization, drug-coated technologies, atherectomy, pedal loop reconstruction, and multidisciplinary diabetic foot care.

Results: Below-the-knee intervention can improve limb perfusion, promote wound healing, reduce rest pain, and support limb salvage. Outcomes depend on lesion complexity, infection control, renal function, wound severity, pedal arch status, and post-procedural wound care.

Conclusion: Endovascular below-the-knee intervention is a key component of diabetic limb-salvage care. Best outcomes require patient selection, precise revascularization, aggressive infection management, and coordinated vascular, podiatric, diabetic, and wound-care follow-up.