CLI at a crossroads: Which direction now?

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Michael Belkin speaks during WVS 2021

Vascular surgery once again finds itself at a crossroads, Michael Belkin, MD, chief of the division of vascular and endovascular surgery at Brigham and Women’s Hospital in Boston, told the Western Vascular Society (WVS) annual meeting (Oct. 16–19) in Jackson Hole, Wyoming, during a presidential guest lecture on the art and science of critical limb ischemia (CLI).

“Again, it’s an existential crossroads,” he told attendees. “We made the right decision last time, years ago, when we adopted interventional therapies as part of what we do as vascular surgeons, and I think, again, we now have to embrace all our tools.” Belkin was discussing bypass surgery and the question of whether it would be a lost art, and whether endovascular-first would become endovascular-only.

“The question is: Can we reproduce the results of PREVENT III? PREVENT III was done by a generation of surgeons who were bypass-first,” Belkin said. Will those be reproduced by the current BASIL and BEST-CLI trials? He has his doubts: “The art of bypass surgery, I think, is threatened.”

So, to the crossroads: “With endo, we have to leverage the technology and advanced technical skills we have to get the best results, but we have to use it in an evidence-based application,” he argued. “And we have to maintain our open skills so that we can offer patients the best therapy for them.

“To those of us who are privileged to train the next generation of surgeons: it’s on us to make sure that our trainees are exposed to the technical aspects—judgmental aspects—of bypass surgery so that they can carry this on in the future.”

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