Surgery or Endovascular Therapy for Chronic Limb-Threatening Ischemia


Publication abstract is copied below


Patients with chronic limb-threatening ischemia (CLTI) require revascularization to improve limb perfusion and thereby limit the risk of amputation. It is uncertain whether an initial strategy of endovascular therapy or surgical revascularization for CLTI is superior for improving limb outcomes.


In this international, randomized trial, we enrolled 1830 patients with CLTI and infrainguinal peripheral artery disease in two parallel-cohort trials. Patients who had a single segment of great saphenous vein that could be used for surgery were assigned to cohort 1. Patients who needed an alternative bypass conduit were assigned to cohort 2. The primary outcome was a composite of a major adverse limb event — which was defined as amputation above the ankle or a major limb reintervention (a new bypass graft or graft revision, thrombectomy, or thrombolysis) — or death from any cause.


In cohort 1, after a median follow-up of 2.7 years, a primary-outcome event occurred in 302 of 709 patients (42.6%) in the surgical group and in 408 of 711 patients (57.4%) in the endovascular group (hazard ratio, 0.68; 95% confidence interval [CI], 0.59 to 0.79; P<0.001). In cohort 2, a primary-outcome event occurred in 83 of 194 patients (42.8%) in the surgical group and in 95 of 199 patients (47.7%) in the endovascular group (hazard ratio, 0.79; 95% CI, 0.58 to 1.06; P = 0.12) after a median follow-up of 1.6 years. The incidence of adverse events was similar in the two groups in the two cohorts.


Among patients with CLTI who had an adequate great saphenous vein for surgical revascularization (cohort 1), the incidence of a major adverse limb event or death was significantly lower in the surgical group than in the endovascular group. Among the patients who lacked an adequate saphenous vein conduit (cohort 2), the outcomes in the two groups were similar.

The chapter below is not from the BEST-CLI trial


With Transit Time Flow Measurement (TTFM) combined with High-Frequency Ultrasound (HFUS) Medistim is offering unique intraoperative quality assessment tools providing immediate feedback during lower limb bypass surgery. TTFM has been shown to be an important parameter for predicting graft patency.

The images show a visible occlusion in the vein graft and how TTFM can reveal open side-branches (Image 2) which is confirmed by HFUS (Image 3).

Please click this link to read more about what the Medistim technology can offer for peripheral bypass as well as the link to the Vascular Guidebook explaining in depth the technology being used during different vascular procedures.


Surgery or endovascular therapy for chronic limb-threatening ischemia. Farber A, Menard MT, Conte MS, et al. N Engl J Med 2022;387:2305-2316.

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