Vein mapping for lower extremity bypass in patients with chronic limb-threatening ischemia (CLTI) remains unchanged two years after the BEST-CLI, “revealing the difficulty in changing practice patterns based on new evidence,” according to the authors behind a new retrospective multicenter study analyzing vein mapping performance before and after the landmark trial.
First results from the BEST-CLI randomized controlled trial (RCT) of 1,830 patients showed that surgical bypass with adequate single-segment great saphenous vein (GSV) is a more effective revascularization strategy for patients with CLTI who are deemed to be suitable for either an open or endovascular approach.
Multiple studies prior to the publication of BEST-CLI reported that vein bypass in patients with CLTI is underutilized, says Indrani Sen, MBBS, a vascular surgeon at the Mayo Clinic Health System in Eau Claire, Wisconsin. “GSV, mapping availability and adequacy remains largely unreported, with an estimated 20–40% patients having GSV that is unusable.”
Sen and colleagues looked at 1,480 consecutive patients with peripheral arterial disease (PAD) undergoing infrainguinal open or endovascular intervention for TASC C and D femoropopliteal occlusion between November 2020 and November 2024—857 patients in a cohort representing those treated before November 2022 (group one), when BEST-CLI was published, and 623 in a cohort treated after the publication date (group two).
Aiming to establish whether BEST-CLI influenced an increase in vein mapping and vein utilization for infrainguinal vein bypass in patients with PAD and in the subgroup with CLTI, they ultimately established that the practice was unchanged during the two study periods, with vein mapping being performed in about 50% of the cohort, Sen said. The data were presented during the 2025 annual meeting of the Midwestern Vascular Surgical Society (MVSS) in Cincinnati, Ohio (Sept. 18–20), by Noora Jabeen, MBBS, a research fellow at the Mayo Clinic in Eau Claire.
“The lower extremity was mapped in, overall, 80% of the cohort—315 in group one vs. 259 in group two. Upper extremity vein mapping was performed in only 18%,” explained. Sen. “In terms of vein adequacy per patient, this was adequate in 60%, and totally inadequate in 10%; this was not different among the two time periods.”
Endovascular procedure utilization was “around 56% overall and open bypass was similar among the two time periods,” Sen continued. “Of the 1,068 patients with CLTI, endovascular procedures were performed in 603 patients—342 vs. 261 patients in group one and group two, respectively. Vein mapping was performed in this cohort in a third, and when performed was adequate in 58%. In patients with CLTI, open vein bypasses were performed in 275 patients—149 [55%; group one] vs. 126 [65%; group two]—therefore, showing an increase post BEST-CLI. Bypass for CLTI utilized suboptimal vein in 62 patients.”
