SLR - January 2023 - Morgan Gallo, DPM MHSA
Title: Surgery or Endovascular Therapy for Chronic Limb-Threatening IschemiaReference: Farber A, Menard MT, Conte MS, Kaufman JA, Powell RJ, Choudhry NK, Hamza TH, Assmann SF, Creager MA, Cziraky MJ, Dake MD, Jaff MR, Reid D, Siami FS, Sopko G, White CJ, van Over M, Strong MB, Villarreal MF, McKean M, Azene E, Azarbal A, Barleben A, Chew DK, Clavijo LC, Douville Y, Findeiss L, Garg N, Gasper W, Giles KA, Goodney PP, Hawkins BM, Herman CR, Kalish JA, Koopmann MC, Laskowski IA, Mena-Hurtado C, Motaganahalli R, Rowe VL, Schanzer A, Schneider PA, Siracuse JJ, Venermo M, Rosenfield K; BEST-CLI Investigators. Surgery or Endovascular Therapy for Chronic Limb-Threatening Ischemia. N Engl J Med. 2022 Nov 7. doi: 10.1056/NEJMoa2207899. Epub ahead of print. PMID: 36342173.
Level of Evidence: Level I
Reviewed By: Morgan Gallo, DPM MHSA
Residency Program: LECOM/Millcreek Community Hospital
Podiatric Relevance: Limb salvage and wound care often overlap with peripheral vascular disease. There has been much discourse within the vascular community as it relates to the “Best CLI study”, which has been gathering data for years. The finalization of the data and publication is surely to be referenced by our vascular colleges. Knowledge of the study will allow for better communication between departments and provide valuable insight of healing potential status post revascularization.
Methods: The forementioned study is an international randomized control trial which enrolled 1830 patients with infrainguinal peripheral artery disease. Patients were divided into two parallel cohorts. The first cohort included patients with great saphenous veins appropriate for use of bypass. The second cohort was specific to patients needing an alternative conduit of bypass. Cohorts were further subdivided into surgical and endovascular intervention for treatment. Primary outcomes were defined as need for more proximal amputation, major limb reintervention, or death from any cause.
Results: Cohort 1 had a mean follow-up time of 2.7 years. Technical success of the index procedure was 98% in the surgical group and 85% in the endovascular group. Primary outcomes of major adverse limb events or death occurred in 42.6% of the surgical group (302/709) and 57.4% of the endovascular group (408/711). Major reintervention in the surgical group occurred in 9.2% and 23.5% in the endovascular group. Above-ankle amputation occurred in 10.4% of the surgical group and 14.9% of the endovascular group. Incidence of death was similar between the two groups. Cohort 2 had a mean follow-up time of 1.6 years. Technical success of the index procedure was 100% in the surgical group and 80.6% in the endovascular group. Primary outcomes of major adverse limb events or death occurred in 42.8% of the surgical group (83/194) and 47.7%% of the endovascular group (95/199). Time to major reintervention was longer in the surgical group. There was no statistical difference between time to major amputation or death from any cause between the two groups.
Conclusions: Surgery first strategy for patients with good quality single segment great saphenous veins for a conduit was associated with 32% lower risk of major adverse limb events or death when compared to endovascular procedures within the same cohort. In the second cohort, as related to patients without a great saphenous vein for conduit, overall outcomes between surgical intervention and endovascular procedures were not significantly different.