Infrapopliteal CLTI without usable vein — endo-first strategy, the BEST-CLI/BASIL-2 split, and rivaroxaban counselling

Examiner prompts and model answers

How do you stage this leg, and why three stagings? As CLTI by the syndrome definition — PAD with rest pain and a 5-week ulcer, venous, traumatic, embolic and nonatherosclerotic causes excluded — referred urgently to vascular surgery.^[4] Stage the limb by WIfI because wound extent and infection join perfusion in setting amputation risk; stage the arteries by GLASS via the target artery path and limb-based patency; stage the decision by PLAN across patient risk, limb severity and anatomic complexity.^[5][4] Require toe pressures as the preferred haemodynamic measure rather than pulses alone.^[4]

His son cites his friend's bypass — why is your strategy different? Because the friend's leg is not this leg: BEST-CLI's surgery win (MALE-or-death 42.6 versus 57.4%, HR 0.68) belongs to cohort 1 with adequate single-segment saphenous vein, while this man without usable vein lives in cohort 2's world where surgery and endo tie (HR 0.79, nonsignificant).^[8] His mandatory infrapopliteal disease maps directly onto BASIL-2: vein-first versus best-endo-first gave amputation-or-death of 63 versus 53% favouring endo-first (HR 1.35), driven by deaths at 53 versus 45% — so endo-first is the evidence-based strategy, with prosthetic bypass markedly inferior below the knee on patency and limb loss if surgery were forced.^[7][20]

What does revascularisation buy him beyond the limb — and what must you watch? Quality of life improves meaningfully whichever strategy is chosen — BEST-CLI shows cohort-wide gains on every measure, with small endo-favouring gaps on VascuQoL, SF-12 MCS and pain scales and ties on EQ-5D and physical scores.^[21] Then long-term limb surveillance per GVG, because the BASIL-2 deaths were mostly cardiovascular and respiratory: the limb threatens and the system kills, so best medical therapy (antithrombotic, lipid-lowering, antihypertensive, glycaemic agents plus smoking, diet, exercise and foot-care counselling) runs beside the procedure.^[4][7]

What does the post-procedure rivaroxaban buy, stated honestly? Vascular-dose rivaroxaban (2.5 mg twice daily) plus aspirin after lower-limb revascularisation gives a 3-year primary composite of 17.3 versus 19.9% (HR 0.85) across 6564 VOYAGER patients — and the total-events analysis shows 4.4 primary and 12.5 vascular events avoided per 100 participants over 3 years.^[9][10] The honesty: TIMI major bleeding ties (2.65 versus 1.87%, p=0.07) but ISTH major bleeding rises (5.94 versus 4.06%, p=0.007) — so select for bleeding risk, counsel explicitly, and never present it as free benefit.^[9]