Peripheral Vascular Disease Medical Slides

Present the BEST-CLI trial (2022, NEJM): 1830 CLTI patients randomized to surgical bypass-first versus endovascular-first strategy. In patients with adequate saphenous vein (cohort 1): bypass was superior with significantly fewer major adverse limb events and death (42.6% vs 57.4% at median 2.7 years). In patients without adequate vein (cohort 2): no significant difference between prosthetic bypass and endovascular. Teaching message: for CLTI with adequate single-segment great saphenous vein, surgical bypass is the preferred revascularization strategy. Endovascular-first is appropriate when adequate vein is absent, when bypass targets are poor, or when patient comorbidities make bypass high-risk.

Present the CLEVER trial (2012): supervised exercise therapy (SET) vs endovascular revascularization vs optimal medical care for aortoiliac claudication. At 6 months: SET improved peak walking time equally to stenting and significantly more than medical therapy alone. At 18 months: SET was superior to stenting for peak walking time. AHA/ACC guidelines recommend SET as first-line therapy for claudication (Class 1 recommendation). Protocol: 30-50 minutes of treadmill walking 3×/week for ≥12 weeks, walking to near-maximal claudication pain then resting, progressive intensity. Barriers: insurance coverage (Medicare covers SET since 2017), program availability, patient compliance.

Present the SVS WIfI (Wound, Ischemia, and Foot Infection) classification system: W (Wound) — grade 0-3 by depth and location. I (Ischemia) — grade 0-3 by ABI, ankle pressure, toe pressure, and TcPO2. fI (Foot Infection) — grade 0-3 by IDSA/IWGDF criteria. Combined WIfI stage (1-4) predicts 1-year amputation risk: Stage 1 (very low, ~5%), Stage 2 (low, ~10%), Stage 3 (moderate, ~25%), Stage 4 (high, ~40%). Clinical utility: guides urgency of revascularization, helps identify patients who need urgent vascular consultation (WIfI stage ≥3), and provides a common language for multidisciplinary limb salvage teams (vascular surgery, podiatry, infectious disease, wound care).