VS@VAM journalist Will Date and videographer Jean-Philippe Bensoussan caught some VAM 2023 foot traffic outside the BEST-CLI and BASIL-2: Debate, Analysis and Implementation session last week to get their take on the two trials and how it has impacted their practice.
First up, SVS President and vascular surgeon William Shutze, MD with Texas Vascular Associates in Plano, says he is staying a familiar course.
“These are two really amazing, important trials that just came out this year that have profoundly affected the care of vascular patients. And it’s very exciting that the results have been published.
“At the same time, even though the overarching conclusions appear to be different, the way that I have interpreted these trials is it’s reinforced a lot of my own personal biases in the care of vascular patients. “I strongly favor bypass surgery for patients that are healthy and have a good quality vein. However, for patients that fall outside of those parameters, it demonstrate the superiority of endovascular techniques and limb salvage.”
Nicolas Mouawad, MD, chief of vascular and endovascular surgery at McLaren Bay Region in Bay City, Michigan, says the two trials offer much food for thought.
“The long-awaited BEST-CLI and then BASIL-2, which I saw when they gave the information at Charing Cross,. I must say it really has confirmed and validated my current practice. We want to keep [intervention] as minimally invasive as possible, but if you have single-segment great saphenous vein in complex patients with CLTI, then I generally would offer a bypass.
“BEST-CLI is really an opportunity to compare best surgical therapy versus endovascular care. However, with BASIL-2 coming out, this has given us a little bit of a different perspective from what we saw in BEST-CLI. Unfortunately, I think it keeps the waters a little bit muddied, but for me in my current practice, it really just validates what I currently do.”
Lee Kirksey, MD, vice chair of vascular surgery at Cleveland Clinic in Cleveland, Ohio, peripheral arterial disease (PAD) care is about offering the most appropriate care for the individual patient.
“What BASIL-2 as well as BEST-CLI really highlight is the importance of looking at this heterogeneous group of patients with PAD in a more granular fashion. We know that systemic risk of the operation, the patient’s anatomic complexity, the lesion complexity—all of these things should influence and impact how we manage the patients.
“I really look at BEST-CLI and BASIL-2 as highlighting the importance that we need to tailor therapy to the patient in front of us, using all the best available grading classifications, the GLASS scale for anatomic complexity, the WIfI scale in terms of the patient presentation, and then select the appropriate therapy. Really, it endorses the need for team based care so that we have expertise within endovascular therapy, expertise within open surgical bypass. Sometimes there will be some hybrid component of those therapies and we offer the most appropriate therapy for that patient in front of us.
For University of California Los Angeles (UCLA) chief of vascular surgery Vincent Rowe, MD, a BEST-CLI site investigator, diagnosis and screening come to the fore.
“For me, the most important lesson was the outcome the outcome of the patients. I knew that patients with lower extremity disease had a high rate of mortality at four to five years. I didn’t realize it was this high— and even in those treated with endovascular therapy. So that was shocking to me. And I believe it means we’re going to need to try to diagnose these patients earlier. I think we should start screening these patients. I think it will save lives. And then I also believe that it will really help us be able to combat that low survival rate.
“To know that a patient that I operate on either with a stent or a bypass has a low probability of being there in follow up at five years makes me work even harder because, even though they may not be there in five years, I want them there with their leg until they close their eyes.”