CLTI: bypass or endovascular first?

At PVI 2025, Prof. Peter Schneider revisits the ongoing debate between bypass surgery and endovascular treatment in patients with chronic limb-threatening ischemia (CLTI), drawing on insights from the landmark BEST-CLI trial. 

While the study demonstrated a clear benefit of bypass in patients with a suitable saphenous vein, particularly through reduced major adverse limb events and reinterventions, its findings apply to a highly selected population. In real-world practice, patient profiles are often more complex. Surgical fitness, lesion morphology, and clinical severity all influence decision-making. 

Prof. Schneider highlights that bypass remains the preferred option in a narrow subset of patients—those who combine good vein quality, surgical eligibility, complex anatomy (GLASS III), and advanced limb threat (WIfI stage IV). However, this represents a minority. 
For the vast majority—estimated at over 80%—endovascular strategies remain highly effective, even in the presence of an available saphenous vein, reflecting a more pragmatic and individualised treatment approach.

A nuanced take on trial data and real-world practice: hit play to see where the balance truly lies!