BEST-CLI Trial
Details
BEST-CLI compared surgical bypass with endovascular therapy in patients with chronic limb-threatening ischaemia (CLTI) who were candidates for both approaches. Its key finding is that when an adequate single-segment saphenous vein is available, surgical bypass is superior — a result that makes conduit availability, not anatomy alone, the deciding variable. (sources/PVD-AHA-2024, rating: very high)
Key Facts
- Population: CLTI with both surgical and endovascular options. (sources/PVD-AHA-2024, rating: very high)
- Cohort 1 — adequate single-segment saphenous vein: surgical bypass superior to endovascular therapy, with a primary composite outcome of 42.6% vs 57.4% (HR 0.68). (sources/PVD-AHA-2024, rating: very high)
- The mechanism of benefit was fewer repeat revascularisations, rather than a mortality difference. (sources/PVD-AHA-2024, rating: very high)
- The 2024 ACC/AHA PAD guideline cites BEST-CLI as one of the key trials underpinning its CLTI revascularisation recommendations. (sources/PVD-AHA-2024, rating: very high)
Contradictions / Open Questions
- BEST-CLI and BASIL-2 point in opposite directions, and the contrast is anatomical: BEST-CLI's benefit was in patients with a good vein conduit, whereas BASIL-2 found endovascular therapy superior in infrapopliteal-dominant disease. The guideline resolves this by recommending individualisation rather than a single default. (sources/PVD-AHA-2024, rating: very high)
- The result applies to cohort 1 only. The wiki's source summary does not report the cohort without an adequate vein, so the trial cannot be read as "bypass is better for CLTI" in general. (sources/PVD-AHA-2024, rating: very high)
- Conduit quality and operator expertise are effect modifiers that a trial cannot randomise, so the same anatomy may be treated differently at centres with different surgical volumes.
Connections
- Related to concepts/CLTI — revascularisation strategy and WIfI/GLASS staging
- Related to concepts/PAD-Medical-Therapy — medical therapy alongside revascularisation
- Related to entities/BASIL-2-Trial — the contrasting infrapopliteal trial
- Related to entities/Peripheral-Artery-Disease — the broader disease spectrum