SVS webinar discusses BEST-CLI and early impacts on practice

A RECORDING OF THE INAUGURAL “SVS Presents” virtual educational session, on the BEST-CLI (Best endovascular versus best surgical therapy in patients with critical limb ischemia) trial and its effect on vascular surgery, is now available.

More than 150 people joined the webcast, which discussed the results from BEST-CLI. The trial aimed to pinpoint the best treatment for patients with peripheral arterial disease (PAD) associated with CLI, or chronic limb-threatening ischemia (CLTI); the webcast also dove into what the results mean for the vascular surgery community.

Trial principal investigators, and SVS members Alik Farber, MD, and Matthew Menard, MD, took part. Caitlin Hicks, MD, and Vincent Rowe, MD, moderated.

Polling on two questions took place before the webcast, with 81 attendees responding. Surgeons reported on their paradigm for treating CLTI prior to the trial results and whether the results have since changed their practices. Approximately 46% of the respondents reported they performed continued from page 1 that future work is required to determine whether the patients enrolled in BASIL-2 are more like the patients with a non-optimal vein in the BEST-CLI trial.

During the panel discussion following the BASIL-2 presentations at CX, Andres Schanzer, MD, chief of vascular surgery at the UMass Memorial Medical Center in Worcester, Massachusetts, asked Bradbury and colleagues to cast the findings against the backdrop of BEST-CLI. Moakes, who was the statistician for BASIL-2, explained that the team are planning to conduct an individual patient data meta-analysis to answer questions around any relevant differences between the two trials.

‘A trial of two strategies’

Also during the discussion, the panel touched on the evolving landscape of endovascular treatment, with moderator Andrew Holden, MD, director of interventional radiology at Auckland City Hospital in Auckland, New Zealand, asking Bradbury and colleagues whether they had noted a significant change in endovascular practice in the period between BASIL-2 and BASIL-1.

Bradbury noted that, in his interpretation of the data, “there is a much greater willingness now that if you do an endo[vascular], and you are not happy with it, the interventional radiologists will go back and have another go, whereas what we tended to see, I think, in BASIL-1, was that if endo[vascular] did not work, [treatment would] quickly go over to bypass. I think that is the difference.”

CX moderator Dittmar Böckler, MD, professor of surgery at the University of Heidelberg in Heidelberg, Germany, urged the audience to keep in mind the various options that remain open when undertaking an endovascular-first approach. CX Chairman Roger Greenhalgh, MD, underscored the point. “It also came out with BESTCLI that the quality of the vein is important,” he said. “It is very, very crucial that whatever you do first, it does not have to be the last word.”

Böckler said vascular specialists “need to learn from this trial which patient deserves which treatment.” It is not a case of surgery versus endovascular therapy, but rather a case of learning from the data, he added. Bradbury concurred. “It is a trial of two strategies,” he said. “That was what BASIL-1 was. It is quite a difficult concept to get across. We are not comparing a vein bypass with an endovascular treatment. We are in a sense—but what we are saying is, ‘What do you do first?’ If you have got equipoise, if you are really on the fence, and you do not know which to do, this trial suggests fairly strongly, I would suggest, that in this subgroup of patients, that you should go endo[vascular] first.” endovascular therapy first prior to publication of BEST-CLI, while 6% reported they performed open revascularization first. Some 68% reported that the decision depended on other patient factors, and 75% reported that they performed open revascularization first if an appropriate great saphenous vein (GSV) conduit were available.

Trial results showed surgical bypass with adequate single-segment GSV is a more effective revascularization strategy for a patient with CLTI who is deemed to be suitable for either an open surgical or endovascular approach. They also found that both strategies are safe and effective.

When asked if the BEST-CLI trial

EARLY IMPACTS OF BEST-CLI: HAS IT CHANGED PRACTICE? YES NO

28% 31% 41% results have changed their practices, 28% of respondents replied that they had, 31% said that they hadn’t, and 41% said their decision was pending.

At the conclusion of the webinar, attendees were re-polled about the changing landscape of CLTI care. The majority (61%) of respondents reported “more patients will receive open surgery” based on the results of the trial, 4% reported endovascular interventions will take over as first-line therapy despite the trial results, and 35% reported there would be no major changes.

Visit SVSOnDemand.vascular.org to view the recording.