Surgical Revascularization — Best for Limb Ischemia

This editorial interprets findings from the BEST-CLI trial, which compared surgical and endovascular revascularization in patients with chronic limb-threatening ischemia (CLTI). Drawing on historical and contemporary evidence including the BASIL trial, the author emphasizes that autologous vein bypass surgery remains the gold standard when suitable vein conduit is available. In BEST-CLI, patients in cohort 1 (with usable great saphenous vein) had significantly lower rates of amputation or reintervention with surgery compared to endovascular therapy (HR: 0.68), while cohort 2 (using alternative conduits) showed no significant between-group difference. Key insights include better technical success with surgery (98% vs. 85%), reduced major reintervention, and slightly fewer above-ankle amputations. Despite advances in minimally invasive techniques, the editorial argues that surgical bypass offers greater durability and superior outcomes for appropriately selected patients. However, it also notes that older patients, Black patients, and those with renal dysfunction may perform equally well with either modality. The author concludes that the BEST-CLI trial re-establishes the primacy of surgical revascularization in CLTI when anatomical conditions are favorable.

This editorial interprets findings from the BEST-CLI trial, which compared surgical and endovascular revascularization in patients with chronic limb-threatening ischemia (CLTI). Drawing on historical and contemporary evidence including the BASIL trial, the author emphasizes that autologous vein bypass surgery remains the gold standard when suitable vein conduit is available. In BEST-CLI, patients in cohort 1 (with usable great saphenous vein) had significantly lower rates of amputation or reintervention with surgery compared to endovascular therapy (HR: 0.68), while cohort 2 (using alternative conduits) showed no significant between-group difference. Key insights include better technical success with surgery (98% vs. 85%), reduced major reintervention, and slightly fewer above-ankle amputations. Despite advances in minimally invasive techniques, the editorial argues that surgical bypass offers greater durability and superior outcomes for appropriately selected patients. However, it also notes that older patients, Black patients, and those with renal dysfunction may perform equally well with either modality. The author concludes that the BEST-CLI trial re-establishes the primacy of surgical revascularization in CLTI when anatomical conditions are favorable.