Conclusion: Patients with critical limb ischemia secondary to infrainguinal occlusive disease and who are suitable for either angioplasty or surgery have similar short-term results with regard to amputation-free survival with either a bypass surgery-first strategy or a balloon angioplasty-first strategy. Summary: The BASIL trial was designed to compare a surgery-first strategy vs balloon angioplasty-first strategy in patients with rest pain, ulceration, or gangrene of the lower extremity. There were 27 hospitals in the United Kingdom that participated in the study. Investigators randomly assigned 452 patients with severe limb ischemia secondary to infrainguinal disease to receive an angioplasty-first strategy (n = 224) or a surgery-first strategy (n = 228). Analysis was by intention to treat, and the primary end point was amputation-free survival. Patient follow-up ended when the patient reached an end point of either amputation of the trial leg above the ankle or died. Secondary outcomes were all-cause mortality, 30-day morbidity and mortality, health-related quality of life, use of hospital resources, and need for reinterventions. Patients had to be considered suitable for randomization by both consultant vascular surgeons and interventional radiologists. The authors also audited patients from the six top recruiting centers who presented with critical limb ischemia and were thought to be suitable for randomization. After survival curves were examined, a post hoc analysis was done comparing risk of end points occurring between randomization and ≤2 years and end points occurring >2 years. During the 6-month audit, 585 consecutive patients with critical limb ischemia presented to the top six recruiting centers, and 129 (29%) needed suprainguinal revascularization. Of the remaining patients with critical limb ischemia, 220 (48%) were treated without revascularization; therefore, 52% of the patients (n = 236) presenting with critical limb ischemia underwent revascularization. Of these 236 potentially eligible patients, 70 (29%) were regarded as suitable for randomization into the trial, but 22 (31%) refused trial entry, thus leaving 48 for randomization. The audit results thus suggest <10% of the patients presenting with critical limb ischemia would be randomized into the BASIL trial. Overall, 195 (86%) of 228 patients assigned to bypass surgery and 216 (96%) of 224 assigned to balloon angioplasty underwent attempts at their allocated intervention. At the end of the follow-up, 55% of the patients (n = 248) were alive without amputation of the trial leg. Eight percent of patients (n = 38) were alive with amputation, 8% (n = 36) were dead after amputation, and 130 patients were dead without amputation (29%). The immediate technical failure rate for the patients assigned to surgery was 3% (5 of 195). The immediate technical failure rate of the patients assigned to angioplasty was 20% (n = 43). The difference in 30-day mortality between the two treatment strategies was not significant. Surgery was associated with a significantly higher early morbidity rate (53%) than angioplasty (41%). Morbidity events were primarily wound, infectious, and cardiovascular complications. No difference was noted in health related quality of life between the two treatment strategies. First year hospital costs were higher with a surgery-first strategy. At 6 months, the two strategies did not differ with respect to amputation-free survival (adjusted hazard ratio, 0.73, 94% confidence interval, 0.49 to 1.07). After 2 years, surgery seemed to be associated with a significantly reduced risk of future amputations, death, or both. Comment: The article raises several interesting points. It is very difficult to recruit for trials of critical limb ischemic patients. The audit data suggests <10% of the patients screened for the trial would be eligible for randomization. In the short-term, results are similar in patients who are suitable both for angioplasty or surgery. Morbidity and expense are greater with surgery, but long-term amputation-free survival may be improved by a surgery-first strategy. Overall, the trial results would appear to be as expected. With respect to the lower extremities, there is a constant theme with respect to angioplasty and surgery. If short-term results are what matter, and the patient can be treated with either angioplasty or surgery, angioplasty is the likely preferred strategy. However, in patients with suitable anatomy and a reasonable life expectancy, surgery may be a better alternative, accepting longer short-term morbidity as a price for greater long-term durability.