Open surgery

**Selection criteria:**

In 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.therapy [@acc2025-d]. The BEST-critical limb ischemia (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]. The BASIL trial suggested a late survival and amputation-free survival benefit for bypass among patients surviving beyond two years [@basil2005]. In elderly patients, open revascularization remains a durable option with acceptable limb salvage rates, although careful patient selection is required to balance surgical risk and frailty [@yu2025].

**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].