A new study comparing autologous vein bypass to endovascular intervention as the initial revascularization strategy for patients with chronic limb-threatening ischemia (CLTI) requiring infrapopliteal treatment found when patients were carefully matched for comorbidities, outcomes between the two approaches were largely similar, pointing to the importance of individualized treatment selection.
The findings were presented at the 2026 Society for Clinical Vascular Surgery (SCVS) Annual Symposium in San Diego, California (March 28-April 1), offering a real-world counterpoint to the sometimes-conflicting data from landmark randomized trials.
“The results of the BEST-CLI and BASIL-2 trials were somewhat contradictory and a number of studies have since been published to see the real-world experience,” said Hasan Dosluoglu, MD, senior author on the study and chief of the division of vascular surgery at the State University of New York. “Our experience reflects all comers to our practice with full follow-up in a vascular surgeon-led program in a VA setting who adopted advanced endovascular interventions early.”
The study drew from 20 years of institutional experience from January 2004 through March 2024, capturing patients treated under a fully individualized revascularization philosophy. Bypass was selected in just 22% of cases, with endovascular intervention used for the remainder, reflecting a patient-by-patient decision-making framework grounded in clinical presentation, comorbidities, anatomic characteristics and autologous vein graft availability.
In practice, that individualization played out across a wide clinical spectrum. “There were patients who had complex anatomy and had endovascular revascularization, and there were patients who had COPD and CKD who had bypass,” said Dosluoglu.
On unmatched analysis, the bypass group fared better than those who underwent endovascular-first revascularization. But when patients were propensity-matched for comorbidities, the gap narrowed considerably, with outcomes proving comparable between the two strategies despite residual differences in disease complexity and patient age that persisted even among matched pairs.
A particularly striking finding from the matching process itself illuminated just how different the two patient populations tend to be. Only 21% of patients in the endovascular group could be successfully matched to bypass patients, compared to 72% of patients in the open surgery group — a disparity reflecting how profoundly comorbidity burden shapes real-world treatment selection.
“The overall experience suggests that patients who were elected for bypass did better than patients who had endovascular first,” said Dosluoglu. “However, when matched for comorbidities, we found that the outcomes aren’t that different, despite the remaining differences in matched groups such as complexity of disease and age.”
The findings carry practical implications for how CLTI programs are structured. Rather than defaulting to a specialty-driven or reimbursement-influenced approach, the data support a patient-centered model in which each modality is deployed where it fits best.
“The optimum revascularization should not be determined by the individual provider’s specialty or type of reimbursement but should be very much centered on the individual patient,” said Dosluoglu. “Bypass has a definite role in these patients and it’s probably appropriate as the first line in about 20% of patients in our experience, which involves a vascular surgeon-only practice with no financial gain with either approach.”
While that 20% figure may not translate uniformly across all centers, it offers a working benchmark that any CLTI program can use to gauge whether it’s performing too many or too few bypass procedures. Dosluoglu argued that the field needs to broaden how it measures success in this patient population.
“We need more studies on patient-centric outcomes such as quality of life, wound healing and maintenance of independent living rather than just amputation-free survival,” said Dosluoglu. He added that the impact of reimbursement structures on outcomes also warrants dedicated study.
“Deciding on the optimum revascularization strategy is a highly individualized process and open versus endovascular versus hybrid options aren’t competitive but complementary,” said Dosluoglu. “Treat the patient, with the least damage and maximum benefit.”
