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.