Although uncommon, critical hand ischemia (CHI) represents a cause of significant disability because of its effect on hand function. Percutaneous transluminal angioplasty (PTA) is now considered a first-line therapy for above-the-elbow artery disease while there are few data regarding the treatment of below-the-elbow (BTE) arteries. The aim of this study is to review the current literature on BTE vessel PTA and to describe the technical approach. In case of favorable anatomy (absence of inflow arteries disease, standard humeral artery bifurcation), a 4-F antegrade trans-brachial approach is usually the preferred option. Due to the small vessel size and the similarities to coronary and below-the-knee vessels, we consider the BTE vessel treatment as a domain of 0.014" compatible devices. The intraluminal approach is always the preferred technique of guidewire advancement, because the subintimal space in not favorable in BTE vessels. In case of failure of the antegrade approach, retrograde puncture and the radial-ulnar loop technique can be used. Long, low-profile balloons with a diameter between 1.5 and 3.5 mm represent the standard treatment of BTE vessel disease. The use of other devices such as Rotablator, stenting and drug coated balloons has been suggested in very selected cases. Endovascular treatment of BTE vessels is feasible and effective in patients with CHI, with an elevated immediate technical success and satisfactory clinical results.