Below-the-knee (BTK) peripheral arterial disease (PAD) is a significant source of cardiovascular morbidity and mortality. Patients with chronic limb-threatening ischaemia in BTK PAD represent one of the highest-risk cohorts of PAD patients, with little progress having been made regarding long-term patency and mortality over the past four decades. Although conventional balloon angioplasty has long been the standard of care, several novel scaffolds have been introduced over the past decade with promising 1-year patency rates and freedom from clinically driven target limb revascularisation, which may herald a new age of endovascular intervention for BTK PAD. In this review, we present a critical appraisal of the literature surrounding novel scaffolds and drug-eluting technology in the treatment of BTK PAD.