BASIL-2 points towards endovascular-first revascularization strategy in CLTI patients

The first release of data from the much-anticipated randomizedcontrolled trial (RCT) shows open bypass surgery had a lower amputation-free survival rate than the minimally invasive approach, report Jocelyn Hudson and Bryan Kay

9 Comment & Analysis

This month’s Corner Stitch column looks at trainees and the evolving device landscape

17 VAM 2023

Annual meeting centralizes diversity, equity and inclusion www.vascularspecialistonline.com

A VASCULAR MISSION: DEFYING ASSUMPTIONS IN THE FIGHT AGAINST AMPUTATION IN DISADVANTAGED AREAS

By Bryan Kay

LYSSA OCHOA, MD, IS USED to the assumptions. One: ”What a nice program you have.”

Another: “It must be so nice that you can give away all of this charity care.”

Ochoa is the founding vascular surgeon behind the SAVE Clinic in San Antonio, geared in its entirety towards targeting the Texas city’s most socially and economically disadvantaged areas against the backdrop of some of the state’s most eye-watering rates of diabetes-related amputation.

Her answers to these types of questions are to point out that she is not operating a program.

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QUESTION FROM MANJ GOHEL, MD, FROM CAMBRIDGE University Hospitals in Cambridge, England, on what the 2023 Charing Cross (CX) International Symposium audience should take back to their multidisciplinary team meetings from the firsttime presentation of BASIL-2 elicited a stark message from chief investigator Andrew Bradbury, MD: a patient who needs a below-theknee revascularization with or without a femoropopliteal revascularization is likely to do better if they are treated with a best endovascular-first strategy rather than a vein bypass-first approach.

By Bryan Kay

In the BASIL-2 (Bypass versus angioplasty for severe ischemia of the leg) trial of 345 patients with chronic limb-threatening ischemia (CLTI), a best endovascular treatment-first revascularization strategy was associated with better amputation-free survival than a vein bypass-first strategy in those who required an infrapopliteal repair—with or without a more proximal infrainguinal procedure. This result was largely driven by fewer deaths in the best endovascular treatment group. Bradbury, from the University of Birmingham in Birmingham, England, presented this key finding during a CX 2023 podium-first presentation. The results were simultaneously published in The Lancet

“It all seems to be pointing towards attempting an endovascular procedure first, and then if that does not work, doing something else— which could be more endovascular,” Bradbury said in response to Gohel, who was asking a question from the floor of the symposium (April 25–27) taking place in London, England. Alternatively, he added, this could be the point at which the vascular specialist switches over to a bypass approach. BASIL-2, however, “lends quite a lot of weight” to an endovascular-first revascularization strategy, “with all the caveats that we have to consider.”

Bradbury, delivering the data for the first time, revealed that 63% of patients randomized to a vein bypass-first strategy of treatment underwent a major amputation or died during follow-up, compared to just 53% of those allotted to a best endovascular-first approach—

BASIL-2’s primary outcome measure (adjusted hazard ratio 1.35, 95% confidence interval [CI] 1.02–1.08, p=0.037).

“Essentially this means that, in this cohort, a vein bypass revascularization strategy resulted in a 35% increased risk of amputation or death during the follow-up compared with a best endovascular-first revascularization strategy,” Bradbury told the CX audience.

Median survival for the whole cohort was 3.8 years—3.3 years for the vein bypass group and 4.4 for the endovascular arm, he said. “The significant difference we have observed in favor of best endovascular therapy with amputation-free survival is very largely driven by the fact that there were more deaths in the vein bypass group—53% of vein

RESEARCH ON AORTIC SIZE INDEX AS A PREDICTOR OF AAAs IN MEN VS WOMEN HIGHLIGHTS IMPORTANCE OF EVIDENCE-BASED PRACTICE

By Éva Malpass

Seeking a better understanding of why women with ruptured abdominal aortic aneurysms (AAAs) have worse outcomes when compared with men, a new study champions adherence to “evidence-based practice” to challenge gender disparities within vascular surgery, in pursuit of sustained conversation about these differences within policy and research spaces.

Presented at the 2023

Women’s Vascular Summit in Buffalo, New York (April 28–29), lead author Blake Murphy, MD, an integrated vascular surgery resident from the University of

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