Importance of Preserving Great Saphenous Vein for Bypass Surgery:

A Commentary on the Study ” Surgery
or Endovascular Therapy for Chronic Limb-Threatening Ischemia“
In patients with chronic severe limb
ischemia (CLTI), vascular reconstruction is often necessary to improve limb
perfusion and reduce the risk of amputation. This multinational randomized
trial recruited 1830 CLTI patients from 150 medical institutions in the United
States, Canada, Finland, Italy, and New Zealand. Patients with available great
saphenous vein for bypass surgery were allocated to Cohort 1, while those
lacking suitable autogenous conduit were allocated to Cohort 2. Each cohort
underwent bypass surgery or endovascular therapy in a 1:1 ratio.
The results of the BEST-CLI study,
published in the New England Journal of Medicine in 2022, revealed that in
Cohort 1, after a median follow-up of 2.7 years, the primary limb adverse event
or death rate was significantly lower in the autogenous vein bypass surgery group
(42.6%) compared to the endovascular group (57.4%) (hazard ratio, 0.68; 95%
confidence interval [CI], 0.59 to 0.79; P < 0.001). In Cohort 2, with a
median follow-up of 1.6 years, the surgical group had 42.8% of patients
experiencing primary limb adverse events, while the endovascular group had
47.7% (hazard ratio, 0.79; 95% CI, 0.58 to 1.06; P = 0.12). The adverse event
rates were similar in both cohorts.
Conclusion: In CLTI patients with an
available great saphenous vein for surgical revascularization (Cohort 1), the
autogenous vein bypass surgery group demonstrated significantly lower rates of
primary limb adverse events or death compared to the endovascular group. For
patients lacking great saphenous vein as a graft conduit (Cohort 2), the
outcomes of bypass surgery were comparable to endovascular therapy.
This study provides important evidence
supporting the value of preserving the great saphenous vein for bypass surgery
in CLTI patients. The findings offer valuable guidance for clinical
decision-making and underscore the significance of utilizing autogenous vein
bypass when feasible.
For further inquiries regarding this
research, readers can contact Dr. Farber at
or reach out to the Division of Vascular and Endovascular Surgery, Boston
Medical Center, Boston University School of Medicine, Department of Surgery, 85
E. Concord St., 3rd Fl., Rm. 3000, Boston, MA 02118.

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