Journal Review in Vascular Surgery: Chronic Limb Threatening Ischemia: BEST-CLI and BASIL-2 Trials

Behind The Knife: The Surgery Podcast

Science, Health & Fitness, Medicine, Education

4.8 • 1.4K Ratings

🗓️ 20 November 2023

⏱️ 27 minutes

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Summary

What is the best surgical treatment for a vasculopathy with critical limb threatening ischemia? In this episode of Behind the Knife the vascular surgery subspecialty team discusses two pivotal trials (BEST-CLI and BASIL-2) and how the findings of these trials can help answer this question. In this episode, we will discuss the age old question: open bypass versus best endovascular treatment.

Hosts:

Dr. Bobby Beaulieu is an Assistant Professor of Vascular Surgery at the University of Michigan
Dr. Frank Davis is an Assistant Professor of Vascular Surgery at the University of Michigan
Dr. David Schechtman is a Vascular Surgery Fellow at the University of Michigan
Dr. Drew Braet is a PGY-4 Integrated Vascular Surgery Resident at the University of Michigan

Learning Objectives

Review the definition, prevalence, and prognosis of critical limb threatening ischemia
Review basic treatment options for patients with critical limb threatening ischemia
Understand the methodology, findings, limitations, and clinical applications of the BEST-CLI trial
Understand the methodology, findings, limitations, and clinical applications of the BASIL-2 trial
Compare open bypass and best endovascular therapy for patients with critical limb threatening ischemia

References

Farber A, Menard MT, Conte MS, Kaufman JA, Powell RJ, Choudhry NK, Hamza TH, Assmann SF, Creager MA, Cziraky MJ, Dake MD, Jaff MR, Reid D, Siami FS, Sopko G, White CJ, van Over M, Strong MB, Villarreal MF, McKean M, Azene E, Azarbal A, Barleben A, Chew DK, Clavijo LC, Douville Y, Findeiss L, Garg N, Gasper W, Giles KA, Goodney PP, Hawkins BM, Herman CR, Kalish JA, Koopmann MC, Laskowski IA, Mena-Hurtado C, Motaganahalli R, Rowe VL, Schanzer A, Schneider PA, Siracuse JJ, Venermo M, Rosenfield K; BEST-CLI Investigators. Surgery or Endovascular Therapy for Chronic Limb-Threatening Ischemia. N Engl J Med. 2022 Dec 22;387(25):2305-2316. doi: 10.1056/NEJMoa2207899. Epub 2022 Nov 7. PMID: 36342173. https://pubmed.ncbi.nlm.nih.gov/36342173/
Bradbury AW, Moakes CA, Popplewell M, Meecham L, Bate GR, Kelly L, et al. A vein bypass first versus a best endovascular treatment first revascularisation strategy for patients with chronic limb threatening ischaemia who required an infra-popliteal, with or without an additional more proximal infra-inguinal revascularisation procedure to restore limb perfusion (BASIL-2): an open-label, randomised, multicentre, phase 3 trial. The Lancet. 2023. 401(10390), 1798-1809. https://doi.org/10.1016/S0140-6736(23)00462-2
Conte MS Bradbury AW Kolh P et al. Global vascular guidelines on the management of chronic limb-threatening ischemia. Eur J Vasc Endovasc Surg. 2019; 58 (109.e33.): S1-109 https://pubmed.ncbi.nlm.nih.gov/31182334/
Bradbury AW Adam DJ Bell J et al. Multicentre randomised controlled trial of the clinical and cost-effectiveness of a bypass-surgery-first versus a balloon-angioplasty-first revascularisation strategy for severe limb ischaemia due to infrainguinal disease. The bypass versus angioplasty in severe ischaemia of the leg (BASIL) trial. Health Technol Assess. 2010; 14: 1-210 https://pubmed.ncbi.nlm.nih.gov/20307380/
Adam DJ Beard JD Cleveland T et al. Bypass versus angioplasty in severe ischaemia of the leg (BASIL): multicentre, randomised controlled trial. Lancet. 2005; 366: 1925-1934 https://pubmed.ncbi.nlm.nih.gov/16325694/
Bradbury AW Adam DJ Bell J et al. Bypass versus angioplasty in severe ischaemia of the leg (BASIL) trial: an intention-to-treat analysis of amputation-free and overall survival in patients randomized to a bypass surgery-first or a balloon angioplasty-first revascularization strategy. J Vasc Surg. 2010; 51: 5S-17 https://pubmed.ncbi.nlm.nih.gov/20435258/
Conte MS, Bradbury AW, Kolh P, White JV, Dick F, Fitridge R, Mills JL, Ricco JB, Suresh KR, Murad MH; GVG Writing Group. Global vascular guidelines on the management of chronic limb-threatening ischemia. J Vasc Surg. 2019 Jun;69(6S):3S-125S.e40. doi: 10.1016/j.jvs.2019.02.016. Epub 2019 May 28. Erratum in: J Vasc Surg. 2019 Aug;70(2):662. PMID: 31159978; PMCID: PMC8365864. https://pubmed.ncbi.nlm.nih.gov/31159978/
Menard MT, Rosenfield K, Farber A. The BEST-CLI Trial: Implications of the Primary Results. Eur J Vasc Endovasc Surg. 2023 Mar;65(3):317-319. doi: 10.1016/j.ejvs.2022.12.032. Epub 2023 Jan 6. PMID: 36621707. https://pubmed.ncbi.nlm.nih.gov/36621707/

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Transcript

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0:00.0	Behind the surgery podcast, relevant and engaging content designed to help you dominate the day. Ladies and gentlemen, I am thrilled to introduce the third edition of the Behind the
0:30.0	Knife Absight Podcast Companion. This latest version offers enhanced images with
0:36.1	immersive audio content for each section making it an unparalleled educational
0:41.1	resource. We've expanded our content with new chapters covering topics like
0:46.0	MIS, oncology, Ooby-G-Y-N, urology, and more. You can find the book in both print and e-book formats on Amazon.
0:56.2	Get ready to elevate your knowledge and achieve top absight scores with the all new behind
1:00.8	the knife absite Podcast Companion,
1:03.3	an indispensable partner on your path to surgical excellence.
1:07.1	Good luck on the upcoming Absite exam
1:09.2	and dominate the day.
1:11.9	Hey everyone, welcome back to the Behind the Knife Podcast. This is your
1:15.4	vascular surgery sub-specialty team from the University of Michigan. We're excited
1:20.0	to be back and speaking to all for another episode. I'm Drew Brayt here along
1:23.4	with doctors Bobby Bolieu, Frank Davis, and David Shekvan. Today we're going to
1:28.9	discuss two pivotal trials in vascular surgery, the best CLI trial, and the Basile 2 trial.
1:35.8	And both of these trials have a focus on the surgical management of patients with
1:39.5	chronic limb-threatening aschemia.
1:41.6	So chronic limb-threatening aschemia. So chronic limb
1:43.4	threatening is scheme or CLTI as we often call it is really the end
1:47.7	stage of peripheral arterial disease and unfortunately it's very common and
1:51.8	affects about 25 million people worldwide.
1:55.6	So that's about 11% of patients who have PAD.
	...

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