Getting lost – and found – in revascularising chronic limb-threatening ischaemia

“Evidence-based medicine is not restricted to randomised trials and meta-analyses. (...) Evidence-based medicine means integrating the best available external clinical evidence with individual clinical expertise.”1

Atherosclerotic disease leading to stenosis or occlusion of the arteries supplying the lower limbs (peripheral artery disease) is the third cause of cardiovascular morbidity after coronary artery disease and stroke. Chronic limb-threatening ischaemia (CLTI), with a high amputation rate and annual mortality of ~10%, is the most severe presentation of peripheral artery disease2. Effective pharmacological management is lacking; thus, revascularisation is the fundamental treatment modality – but the best methods remain debated34567 (Table 1). The goals of revascularisation include resting pain relief, limb salvage, and prevention of systemic complications.

BEST-CLI found that – for patients with optimal material for vein bypass (defined as single-segment great saphenous vein) – surgery led to a lower combined rate of major adverse limb events (MALE; above-ankle amputation or major reintervention) and death than endovascular therapy (endo) (42.6% vs 57.4%; p<0.001). However, in those without an optimal vein available (up to 50%...