Open surgery

in Lower Extremity Arterial Disease

Applied

Type

Addition

Confidence

90%

Created

Mar 19, 2026

Evidence

2 sources

Rationale

The integration expands on the 'patient factors' mentioned in the original text by incorporating high-level evidence regarding diabetes management (ACC 2025) and socioeconomic disparities (Zil-E-Ali 2024). These additions provide necessary context for modern surgical decision-making in CLTI. All abbreviations were expanded on first use as required, and existing trial data (BEST-CLI, BASIL) were preserved while clarifying their full names and abbreviations.

Evidence

Das SR et al. Management of Peripheral Artery Disease in Adults With Diabetes: 2025 ACC Scientific Statement: A Report of the American College of Cardiology. J Am Coll Cardiol. 2025. PMID: 41405527.
Verified source
PubMedDOI
Zil-E-Ali A et al. A systematic review to examine the impact of socioeconomic status on revascularization for peripheral arterial disease, carotid artery surgery, and aortic aneurysm repair outcomes in the United States. J Vasc Surg. 2024. PMID: 39486599.
Verified source
PubMedDOI

Content Changes

**Selection of bypass versus endovascular therapy in chronic limb-threatening ischemia (CLTI)** is guided by conduit availability, anatomic complexity, and patient factors.factors, Theincluding BEST-criticalcomorbidities and socioeconomic status (SES). In patients with diabetes mellitus (DM), the 2025 American College of Cardiology (ACC) scientific statement emphasizes that revascularization decisions should occur within a multidisciplinary framework to optimize limb ischemiasalvage (CLI)and manage the high systemic cardiovascular risk associated with the disease [@acc2025-c]. Furthermore, SES has been identified as a critical determinant of access to care and long-term outcomes following revascularization for peripheral artery disease (PAD) [@anon2024].

The Best Endovascular versus Best Surgical Therapy for Patients with Chronic Limb-Threatening Ischemia (BEST-CLI) trial demonstrated that when single-segment great saphenous vein (GSV) is available and anatomic complexity is high (GLASS(Global Anatomic Staging System [GLASS] Stage III or extensive tibial disease), a bypass-first strategy produces superior limb salvage and amputation-free survival (AFS) compared with best endovascular therapy (cohort 1). Conversely, when adequate autogenous conduit is unavailable or anatomic complexity is lower (GLASS I–II), endovascular-first and bypass-first approaches achieve comparable outcomes (cohort 2). The BASILBypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial supports bypass-first strategy in patients with life expectancy exceeding 2 years, whereas angioplasty-first is appropriate for patients with limited longevity or prohibitive surgical risk [@bestcli2022, @basil2005, @conte2019].

For popliteal artery aneurysm causing acute limb ischemia,ischemia (ALI), see [[Aneurysms of the Lower Extremities|Chapter 5]].
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