Update on BEST-CLI Trial Alik Farber, M.D. Professor and Chief Division of Vascular and Endovascular Surgery Boston Medical Center Boston University School of Medicine Disclosures Trial Co-Chair  Supported by NHLBI: 1U01HL107407-01A1 A Growing Problem PAD/CLI Elderly Metabolic Syndrome Obesity Diabetes An Expensive Problem • Medicare expenditure on CLI > $4 billion (CHF = $3.9B, Cerebrovascular disease = $3.7B) – 90% inpatient care – $1,700 per patient (>2X avg beneficiary) – 3% of total Medicare budget (THR = 0.9%, TKR 1.7%) Natural History of Critical Limb Ischemia >1,500 patients in 13 studies at 1 year f/u --22% mortality --35% worsening tissue loss --22% major amputation rate Goals Of Treatment • Medical therapy to optimize cardiovascular risk • Measures to improve limb perfusion (revascularization) – Relieve pain – Heal wounds – Preserve a functional limb – Maintain ambulatory status Hirsch AT et al. J Am Coll Cardiol 2006;47:1239-131 Conte MS and Farber A. BJS 2015;102:1007-1009 Current State of Affairs in CLI  Most CLI is treated with infrainguinal revascularization Endovascular Therapy Bypass Surgery Current State of Affairs in CLI  Most CLI is treated with infrainguinal revascularization  There is great variation in amputation and revascularization rates in patients with CLI (Dartmouth Atlas, 1998)  Amputation rates among certain groups are rising (Humphries JVS 2016)  There is variability in intensity of vascular care across regions of the United States (Goodney. Circulation CV 2012)  There is great variability in how open surgery and endovascular therapy is utilized to treat CLI (Menard. JAHA 2016) Critical Limb Ischemia: % Treated by Bypass (vs. PVI) 100% Bypass 100% 90% 80% 70% Procedure Selection Variation 60% 50% 40% 30% 20% 10% 0% VQI Centers 0% Bypass