Surgery or Endovascular Therapy for Chronic Limb-Threatening Ischemia

The BEST-CLI trial was a multicenter, randomized study evaluating surgical versus endovascular revascularization for chronic limb-threatening ischemia (CLTI) in patients with infrainguinal peripheral artery disease. A total of 1830 patients were stratified into two cohorts: cohort 1 included those with a usable single segment of great saphenous vein; cohort 2 included those requiring alternative conduits. In cohort 1, surgical revascularization significantly reduced the composite endpoint of major adverse limb events or death (42.6% vs. 57.4%; HR: 0.68; 95% CI: 0.59–0.79; P<0.001), driven by lower rates of major reintervention and above-ankle amputation. In cohort 2, outcomes were similar between surgical and endovascular groups (42.8% vs. 47.7%; HR: 0.79; 95% CI: 0.58–1.06; P=0.12). Technical success was higher with surgery (98% vs. 85% in cohort 1), and adverse cardiovascular events were comparable between strategies. The study supports surgery-first treatment for CLTI when a suitable vein conduit is available, and individualized decision-making otherwise, highlighting the importance of anatomical, clinical, and patient-preference factors.

The BEST-CLI trial was a multicenter, randomized study evaluating surgical versus endovascular revascularization for chronic limb-threatening ischemia (CLTI) in patients with infrainguinal peripheral artery disease. A total of 1830 patients were stratified into two cohorts: cohort 1 included those with a usable single segment of great saphenous vein; cohort 2 included those requiring alternative conduits. In cohort 1, surgical revascularization significantly reduced the composite endpoint of major adverse limb events or death (42.6% vs. 57.4%; HR: 0.68; 95% CI: 0.59–0.79; P<0.001), driven by lower rates of major reintervention and above-ankle amputation. In cohort 2, outcomes were similar between surgical and endovascular groups (42.8% vs. 47.7%; HR: 0.79; 95% CI: 0.58–1.06; P=0.12). Technical success was higher with surgery (98% vs. 85% in cohort 1), and adverse cardiovascular events were comparable between strategies. The study supports surgery-first treatment for CLTI when a suitable vein conduit is available, and individualized decision-making otherwise, highlighting the importance of anatomical, clinical, and patient-preference factors.