Practice Patterns in the Management of Chronic Limb Threatening Ischemia by BEST-CLI Investigators

Author Type(s)

Faculty

Document Type

Abstract

Publication Date

6-2023

DOI

10.1016/j.jvs.2023.03.247

Journal Title

Journal of Vascular Surgery

Department

Surgery

Abstract

Objectives

BEST-CLI trial investigators had diverse practice patterns in treating complex chronic limb-threatening ischemia (CLTI). We assessed investigator practices and comfort towards complex open surgical and endovascular procedures.

Methods

An electronic survey was sent out to 1180 BEST-CLI investigators at 150 sites in 2022, after trial conclusion and before announcement of results. The survey consisted of 43 questions focused on practice patterns.

Results

There were 238 investigators (20.2%) that submitted responses. Respondents were 80% male, 68.2% White, and 15.3% from outside the United States. Respondents included vascular surgeons (76.3%), interventional cardiologists (11.4%), and interventional radiologists (11.6%). The majority (72.6%) were in academic practice, with 39.1% in practice >20 years and 30.5% in practice 11 to 20 years. For initial CLTI workup, respondents always/usually ordered an arterial duplex (65.8%), computed tomography angiography (42.6%), magnetic resonance angiography (4.5%), and vein mapping (55.9%). Surgeon case volumes in a typical year, recorded as 0, 1 to 10, and >10, for alternative autogenous vein were 12.6%, 69.5%, and 17.8%; composite vein 17.2%, 79.9%, and 2.9%; prosthetic conduit 4%, 84.6%, and 11.4%; composite sequential bypass 58.8%, 38.2%, and 2.9%; bypass to pedal targets 8%, 81.7%, and 10.3%; and hybrid procedures 2.3%, 56.7%, and 41%. Postoperatively, 99% and 81.9% reported performing routine duplex surveillance of vein and prosthetic bypass, respectively. Among all interventionalists, yearly endovascular interventions were 0, 1 to 10, and >10, utilized radial access 54.5%, 37.6%, and 8%; pedal/tibial access 24%, 61%, and 24%; pedal loop revascularization 62.3%, 29.7%; 8%. The majority (86%) ordered routine duplex surveillance following endovascular revascularization. Most respondents reported routinely using paclitaxel balloons (88.1%) and stents (67.5%). There were 73.3% that altered practice when safety concerns were raised, whereas 63.9% resumed use of these devices. A minority reported always/usually using WIfI (25.8%), GLASS (8.3%), and a risk calculator (14.8%) in their clinical practice.

Conclusions

There is a wide range of practice patterns among vascular specialists treating CLTI. The majority of investigators in BEST-CLI had experience in both advanced open and endovascular techniques and represent a real-world sample of technical expertise.

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