Open surgery

in Lower Extremity Arterial Disease

Applied

Type

Modification

Confidence

92%

Created

Apr 26, 2026

Evidence

1 source

Rationale

The stale guideline replacement target acc 2025 c was replaced with the superseding 2026 ACC/AHA lower extremity PAD guideline ACC/AHA for the same claim about multidisciplinary revascularization decision-making in DM patients. The citation key ACC/AHA already exists in the chapter's existing citation key list, confirming it is the correct superseding source. No other substantive content changes were required, as the new article does not introduce additional claims beyond what is already covered in this section.

Evidence

ACC/AHA. Management of Lower Extremity Peripheral Artery Disease: Guidelines From the ACC/AHA. 2026. PMID: 41252847.
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, including comorbidities and socioeconomic status (SES). In patients with diabetes mellitus (DM), the 2025 American College of Cardiology (ACC)2026 scientificACC/AHA statementguidelines emphasizesemphasize that revascularization decisions should occur within a multidisciplinary framework to optimize limb salvage and manage the high systemic cardiovascular risk associated with the disease [@acc2025-c].[@acc2026-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 (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 Bypass 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 (ALI), see [[Aneurysms of the Lower Extremities|Chapter 5]].
Go to section in textbookDispute / Submit evidenceAll updates