Purpose of Review <p>The purpose of this paper is to review the current role of intravascular imaging (IVI) in the diagnosis and management of peripheral artery disease (PAD) through its application in endovascular interventions of the lower extremities.</p> Recent Findings <p>IVI, an established adjunctive tool for coronary intervention, has become increasingly used during peripheral endovascular revascularizations. Intravascular ultrasound (IVUS) is the predominant IVI modality used during peripheral intervention. The use of optical coherence tomography (OCT) in the peripheral vasculature is limited. Growing data from retrospective studies, meta-analyses and new clinical trials have demonstrated that IVUS-guidance may improve endovascular procedural and clinical outcomes, such as improved patency and reduced rates of major adverse limb events.</p> Summary <p>IVI provides unique information of the vasculature before, during, and after endovascular intervention. This allows for accurate vessel measurements and detailed lesion characterization, assisting diagnostic dilemmas and guiding procedures to optimize stent deployment (e.g. sizing, apposition, expansion) and detect complications post-intervention (e.g. dissection, stent fracture). Expert consensus largely supports the implementation of IVI, and IVUS specifically, during endovascular interventions for PAD. However, more robust clinical data evaluating the efficacy, safety, long-term outcomes and cost-effectiveness of IVI modalities are still needed.</p>