Open surgery

**Selection criteria:**

In CLTI,chronic limb-threatening ischemia (CLTI), bypass-first should be considered when adequate great saphenous vein (GSV) is available and anatomic complexity is high or after failed endovascular therapy. The BEST-CLI trial showed lower rates of major adverse limb events (MALE) and death with bypass versus endovascular therapy in patients with usable vein; when no adequate vein was available, outcomes were similar between strategies [@bestcli2022]. Recent meta-analytical data reinforces the role of bypass surgery in providing durable limb salvage compared to endovascular therapy in CLTI patients [@ramesh2025]. The BASIL trial suggested a late survival and amputation-free survival benefit for bypass among patients surviving beyond two years [@basil2005]. Furthermore, patient-specific risk factors such as frailty are increasingly recognized as critical determinants of postoperative success, with higher frailty scores correlating with increased morbidity and mortality after open revascularization [@gonzalez2024].

**Post-bypass antithrombotic therapy** can be tailored by conduit: DAPTdual antiplatelet therapy (DAPT) may benefit prosthetic grafts (CASPAR) [@caspar2010], whereas vitamin K antagonists showed mixed results by conduit in the Dutch BOA study [@boa2000].