Abstract：
OBJECTIVE: There has been significant variability in practice patterns and equipoise regarding treatment approach for chronic limb-threatening ischemia (CLTI). We aimed to assess treatment preferences of Best Endovascular vs Best Surgical Therapy in Patients with CLTI (BEST-CLI) investigators prior to and following the trial.
METHODS: An electronic 60-question survey was sent to 1180 BEST-CLI investigators in 2022, after trial conclusion and before announcement of results. Investigators\' preferences were assessed across clinical scenarios for both open (OPEN) and endovascular (ENDO) revascularization strategies. Vascular surgeon (VS) surgical and ENDO preferences were compared with a 2010 survey administered to prospective investigators before trial funding.
RESULTS: For the 2022 survey, the response rate was 20.2% and was comprised of VSs (76.3%), interventional cardiologists (11.4%) and interventional radiologists (11.6%). The majority (72.6%) were in academic practice and 39.1% were in practice for >20 years. During initial CLTI work-up, 65.8%, 42.6%, and 55.9% of respondents always or usually ordered an arterial duplex, computed tomography angiography, and vein mapping, respectively. The most common practice distribution between ENDO and OPEN procedures was 70/30. Postoperatively, a majority reported performing routine duplex surveillance of vein bypass (99%), prosthetic bypass (81.9%), and ENDO interventions (86%). A minority reported always or usually using the wound, ischemia, and foot infection (WIfI) criteria (25.8%), GLASS (8.3%), and a risk calculator (14.8%). More than one-half (52.9%) agreed that the statement \"no bridges are burned with an ENDO-first approach\" was false. Intervention choice was influenced by availability of the operating room or ENDO suite, personal schedule, and personal skill set in 30.1%, 18.0%, and 45.9% of respondents, respectively. Most respondents reported routinely using paclitaxel-coated balloons (88.1%) and stents (67.5%); however, 73.3% altered practice when safety concerns were raised. Among surgeons, 17.8%, 2.9%, and 10.3% reported performing >10 annual alternative autogenous vein bypasses, composite vein composite vein bypasses, and bypasses to pedal targets, respectively. Among all interventionalists, 8%, 24%, and 8% reported performing >10 annual radial access procedures, pedal or tibial access procedures, and pedal loop revascularizations. The majority (89.1%) of respondents felt that CLTI teams improved care; however, only 23.2% had a defined team. The effectiveness of the teamwork at institutions was characterized as highly effective in 42.5%. When comparing responses by VSs to the 2010 survey, there were no changes in preferred treatment based on Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC) II classification or conduit preference. In 2022, OPEN surgery was preferred more for a popliteal occlusion. For clinical scenarios, there were no differences except a decreased proportion of respondents who felt there was equipoise for major tissue loss for major tissue loss (43.8% vs 31.2%) and increased ENDO choice for minor tissue loss (17.6% vs 30.8%) (P < .05).
CONCLUSIONS: 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 ENDO techniques and represent a real-world sample of technical expertise. Over the course of the decade of the BEST-CLI trial, there was overall similar equipoise among VSs.
METHODS: An electronic 60-question survey was sent to 1180 BEST-CLI investigators in 2022, after trial conclusion and before announcement of results. Investigators\' preferences were assessed across clinical scenarios for both open (OPEN) and endovascular (ENDO) revascularization strategies. Vascular surgeon (VS) surgical and ENDO preferences were compared with a 2010 survey administered to prospective investigators before trial funding.
RESULTS: For the 2022 survey, the response rate was 20.2% and was comprised of VSs (76.3%), interventional cardiologists (11.4%) and interventional radiologists (11.6%). The majority (72.6%) were in academic practice and 39.1% were in practice for >20 years. During initial CLTI work-up, 65.8%, 42.6%, and 55.9% of respondents always or usually ordered an arterial duplex, computed tomography angiography, and vein mapping, respectively. The most common practice distribution between ENDO and OPEN procedures was 70/30. Postoperatively, a majority reported performing routine duplex surveillance of vein bypass (99%), prosthetic bypass (81.9%), and ENDO interventions (86%). A minority reported always or usually using the wound, ischemia, and foot infection (WIfI) criteria (25.8%), GLASS (8.3%), and a risk calculator (14.8%). More than one-half (52.9%) agreed that the statement \"no bridges are burned with an ENDO-first approach\" was false. Intervention choice was influenced by availability of the operating room or ENDO suite, personal schedule, and personal skill set in 30.1%, 18.0%, and 45.9% of respondents, respectively. Most respondents reported routinely using paclitaxel-coated balloons (88.1%) and stents (67.5%); however, 73.3% altered practice when safety concerns were raised. Among surgeons, 17.8%, 2.9%, and 10.3% reported performing >10 annual alternative autogenous vein bypasses, composite vein composite vein bypasses, and bypasses to pedal targets, respectively. Among all interventionalists, 8%, 24%, and 8% reported performing >10 annual radial access procedures, pedal or tibial access procedures, and pedal loop revascularizations. The majority (89.1%) of respondents felt that CLTI teams improved care; however, only 23.2% had a defined team. The effectiveness of the teamwork at institutions was characterized as highly effective in 42.5%. When comparing responses by VSs to the 2010 survey, there were no changes in preferred treatment based on Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC) II classification or conduit preference. In 2022, OPEN surgery was preferred more for a popliteal occlusion. For clinical scenarios, there were no differences except a decreased proportion of respondents who felt there was equipoise for major tissue loss for major tissue loss (43.8% vs 31.2%) and increased ENDO choice for minor tissue loss (17.6% vs 30.8%) (P < .05).
CONCLUSIONS: 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 ENDO techniques and represent a real-world sample of technical expertise. Over the course of the decade of the BEST-CLI trial, there was overall similar equipoise among VSs.
摘要：
目的：慢性威胁肢体缺血（CLTI）的治疗方法在实践模式和平衡方面存在显著差异。我们的目的是在试验之前和之后评估BEST-CLI研究者的治疗偏好。
方法：在试验结束后和结果宣布之前，于2022年向1180BEST-CLI研究人员发送了电子60问题调查。在开放（OPEN）和血管内（ENDO）血运重建策略的临床方案中评估了研究者的偏好。将血管外科医生手术和血管内偏好与2010年在试验资助前对前瞻性研究者进行的调查进行比较。
结果：对于2022年的调查，有效率为20.2%，由血管外科医生(76.3%)组成，介入心脏病学家(11.4%)和介入放射学家(11.6%)。大多数（72.6％）在学术实践中，39.1％在实践中超过20年。在初始CLTI工作期间，65.8%,42.6%,55.9%的受访者总是或通常下令动脉双工，计算机断层扫描血管造影，和静脉映射，分别。血管内和开放手术之间最常见的实践分布是70/30。术后,大多数报告说进行了静脉旁路的常规双工监测（99％），假肢搭桥(81.9%),血管内介入治疗（86%）。少数人报告总是或通常使用WIfI(25.8%)，玻璃（8.3%），和风险计算器(14.8%)。超过一半（52.9％）的人同意“使用ENDO优先方法不会烧毁任何桥梁”的说法是错误的。干预选择受手术室或血管内套件的可用性影响，个人日程,个人技能占30.1%，18%和45.9%的受访者，分别。大多数受访者报告常规使用紫杉醇涂层球囊（88.1％）和支架（67.5％），然而，当提出安全问题时，73.3%的人改变了做法。在外科医生中，17.8%,2.9%,10.3%的人报告每年进行10次以上的替代自体静脉旁路，复合静脉复合静脉旁路,绕过踏板目标，分别。在所有干预主义者中，8%,24%,8%的人报告每年执行超过10次放射状手术，踏板或胫骨进入程序,和踏板环路血管重建。大多数(89.1%)的受访者认为CLTI团队改善了护理，然而，只有23.2%的人拥有明确的团队。在机构中，团队合作的有效性被认为是42.5%的高效。当比较血管外科医生对2010年调查的反应时，根据TASCII分类或导管偏好,首选治疗没有变化.2022年，开放手术更适合pop骨闭塞。对于临床情况，除了认为主要组织损失与主要组织损失相当的受访者比例下降外，没有差异(43.8%与31.2%)和增加ENDO对轻微组织损失的选择(17.6%与30.8%)(P<.05)。
结论：在治疗CLTI的血管专家中有广泛的实践模式。BEST-CLI的大多数研究人员在先进的开放和血管内技术方面都有经验，并且代表了现实世界的技术专长样本。在BEST-CLI试验的十年中，血管外科医生之间的平衡总体相似。
方法：在试验结束后和结果宣布之前，于2022年向1180BEST-CLI研究人员发送了电子60问题调查。在开放（OPEN）和血管内（ENDO）血运重建策略的临床方案中评估了研究者的偏好。将血管外科医生手术和血管内偏好与2010年在试验资助前对前瞻性研究者进行的调查进行比较。
结果：对于2022年的调查，有效率为20.2%，由血管外科医生(76.3%)组成，介入心脏病学家(11.4%)和介入放射学家(11.6%)。大多数（72.6％）在学术实践中，39.1％在实践中超过20年。在初始CLTI工作期间，65.8%,42.6%,55.9%的受访者总是或通常下令动脉双工，计算机断层扫描血管造影，和静脉映射，分别。血管内和开放手术之间最常见的实践分布是70/30。术后,大多数报告说进行了静脉旁路的常规双工监测（99％），假肢搭桥(81.9%),血管内介入治疗（86%）。少数人报告总是或通常使用WIfI(25.8%)，玻璃（8.3%），和风险计算器(14.8%)。超过一半（52.9％）的人同意“使用ENDO优先方法不会烧毁任何桥梁”的说法是错误的。干预选择受手术室或血管内套件的可用性影响，个人日程,个人技能占30.1%，18%和45.9%的受访者，分别。大多数受访者报告常规使用紫杉醇涂层球囊（88.1％）和支架（67.5％），然而，当提出安全问题时，73.3%的人改变了做法。在外科医生中，17.8%,2.9%,10.3%的人报告每年进行10次以上的替代自体静脉旁路，复合静脉复合静脉旁路,绕过踏板目标，分别。在所有干预主义者中，8%,24%,8%的人报告每年执行超过10次放射状手术，踏板或胫骨进入程序,和踏板环路血管重建。大多数(89.1%)的受访者认为CLTI团队改善了护理，然而，只有23.2%的人拥有明确的团队。在机构中，团队合作的有效性被认为是42.5%的高效。当比较血管外科医生对2010年调查的反应时，根据TASCII分类或导管偏好,首选治疗没有变化.2022年，开放手术更适合pop骨闭塞。对于临床情况，除了认为主要组织损失与主要组织损失相当的受访者比例下降外，没有差异(43.8%与31.2%)和增加ENDO对轻微组织损失的选择(17.6%与30.8%)(P<.05)。
结论：在治疗CLTI的血管专家中有广泛的实践模式。BEST-CLI的大多数研究人员在先进的开放和血管内技术方面都有经验，并且代表了现实世界的技术专长样本。在BEST-CLI试验的十年中，血管外科医生之间的平衡总体相似。
