The authors are to be congratulated for the detailed examination of the Vascular Quality Initiative (VQI) database to obtain a glimpse of the real-world outcomes of patients with critical limb ischemia (CLI) treated with endovascular peripheral vascular intervention (PVI) vs lower extremity bypass (LEB). Not surprisingly, PVI patients were found to have significantly more comorbidities, lower adjusted perioperative mortalities, and shorter lengths of stay. The perioperative mortality advantage disappeared in the cohorts that focused on patients with better operative risk and simpler anatomy. LEB patients, similar to previous studies, had improved 3-year survivals and improved survival free of major adverse limb events in the overall cohort. This study raises important questions, but similar to previous evaluations of endovascular therapy CLI and Vascular Quality Initiative reports, has significant limitations. Follow-up at 1 year was <50%, and no hemodynamic or detailed anatomic information was available. The most reliable 3-year data (based on Social Security data) confirm the survival advantage to patients undergoing LEB. So how are we to use these data in our own selection of PVI vs LEB for CLI patients? Perhaps this study supports most vascular surgeons' bias that PVI (or even serial PVIs) is the best way to bring our most severely ill CLI patients to the finish line with their legs intact; hopefully, in relative comfort with wounds healed or healing. Unfortunately, this study does little to inform our treatment of the great majority of our patients who live ≥2 years beyond the first intervention for CLI. Vascular surgeons are the most well-equipped clinicians to manage patients with CLI because only we can offer these patients the full range of treatment options, including PVI and LEB. The best application of these complementary techniques depends on accurate comparative effectiveness data based on precise anatomic criteria, hemodynamic results, patency rates, limb salvage rates, wound healing rates, quality of life, and cost effectiveness. As the authors rightly point out, such data awaits completion of randomized prospective trials such as the ongoing Best Endovascular Versus Best Surgical Therapy in Patients With CLI (BEST) trial. I would ask you to consider for one moment the effect previous randomized prospective vascular surgery trials, such as Asymptomatic Carotid Artery Stenosis Study (ACAS), North American Symptomatic Carotid Endarterectomy Trial (NASCET), Carotid Revascularization Endarterectomy vs Stent Trial (CREST), Comparison of Endovascular Aneurysm Repair with Open Repair in Patients with Abdominal Aortic Aneurysm (EVAR), Dutch Randomised Endovascular Aneurysm Management (DREAM), Aneurysm Detection and Management (ADAM), Bypass Versus Angioplasty in Severe Ischaemia of the Leg (BASIL) and Edifoligide for the Prevention of Infrainguinal Vein Graft Fail (PREVENT) among others, have had on our education of patients and trainees as well as our daily practice of vascular and endovascular surgery. We must actively support and enroll in the BEST trial to bring it to successful completion to generate similar data to help guide us in the treatment of our most challenging CLI patients. Only then will vascular surgeons know how to best use our complementary tools of PVI and LEB. Comparison of open and endovascular treatment of patients with critical limb ischemia in the Vascular Quality InitiativeJournal of Vascular SurgeryVol. 63Issue 4PreviewThere is significant controversy in the management of critical limb ischemia (CLI) arising from infrainguinal peripheral arterial disease. We sought to compare practice patterns and perioperative and long-term outcomes for patients undergoing lower extremity bypass (LEB) and percutaneous vascular interventions (PVIs) for CLI in the Vascular Quality Initiative (VQI). Full-Text PDF Open Archive