Practice Patterns in the Management of Chronic Limb Threatening Ischemia by BEST-CLI Investigators

Abstract

BEST-CLI trial investigators had diverse practice patterns in treating complex chronic limb-threatening ischemia (CLTI). We assessed investigator practices and comfort towards complex open surgical and endovascular procedures. An electronic survey was sent out to 1180 BEST-CLI investigators at 150 sites in 2022, after trial conclusion and before announcement of results. The survey consisted of 43 questions focused on practice patterns. There were 238 investigators (20.2%) that submitted responses. Respondents were 80% male, 68.2% White, and 15.3% from outside the United States. Respondents included vascular surgeons (76.3%), interventional cardiologists (11.4%), and interventional radiologists (11.6%). The majority (72.6%) were in academic practice, with 39.1% in practice >20 years and 30.5% in practice 11 to 20 years. For initial CLTI workup, respondents always/usually ordered an arterial duplex (65.8%), computed tomography angiography (42.6%), magnetic resonance angiography (4.5%), and vein mapping (55.9%). Surgeon case volumes in a typical year, recorded as 0, 1 to 10, and >10, for alternative autogenous vein were 12.6%, 69.5%, and 17.8%; composite vein 17.2%, 79.9%, and 2.9%; prosthetic conduit 4%, 84.6%, and 11.4%; composite sequential bypass 58.8%, 38.2%, and 2.9%; bypass to pedal targets 8%, 81.7%, and 10.3%; and hybrid procedures 2.3%, 56.7%, and 41%. Postoperatively, 99% and 81.9% reported performing routine duplex surveillance of vein and prosthetic bypass, respectively. Among all interventionalists, yearly endovascular interventions were 0, 1 to 10, and >10, utilized radial access 54.5%, 37.6%, and 8%; pedal/tibial access 24%, 61%, and 24%; pedal loop revascularization 62.3%, 29.7%; 8%. The majority (86%) ordered routine duplex surveillance following endovascular revascularization. Most respondents reported routinely using paclitaxel balloons (88.1%) and stents (67.5%). There were 73.3% that altered practice when safety concerns were raised, whereas 63.9% resumed use of these devices. A minority reported always/usually using WIfI (25.8%), GLASS (8.3%), and a risk calculator (14.8%) in their clinical practice. There is a wide range of practice patterns among vascular specialists treating CLTI. The majority of investigators in BEST-CLI had experience in both advanced open and endovascular techniques and represent a real-world sample of technical expertise.