An assessment of the BEST-CLI Trial demonstrates that infrainguinal bypass offers a potential advantage in smokers with chronic limb-threatening ischemia

Objective: Smoking is an established risk factor in many pathologies of the cardiovascular system. The Best Endovascular vs Best Surgical Therapy in Patients with Critical Limb Ischemia (BEST-CLI) trial affords an in-depth evaluation into the effect of smoking on patients with chronic limb-threatening ischemia (CLTI). BEST-CLI's prospective, randomized design evaluated outcomes in patients suitable for both open or endovascular intervention and randomized patients between endovascular intervention (ENDO) vs open surgical bypass (OPEN). The outcomes are reported stratified by smoking status. Methods: In the BEST-CLI trial, patients were stratified by current smokers (CS) and nonsmokers (NS), which included both previous smokers or never smokers. Endpoints at 4 years include the primary trial outcomes (major adverse limb events [MALE] or all-cause death), as well as above-ankle amputation, all-cause death, major or minor reintervention, major adverse cardiac events (MACE), MALE, and MALE or perioperative death. Multivariable Cox regression models were created with NS serving as the reference group. Results: Patients received bypass using single-segment saphenous vein (n = 621), bypass using alternative conduits (n = 236), or endovascular procedures (n = 923). There were 641 CSs and 1137 NSs. In the combined cohort of patients receiving ENDO or OPEN, CS status was associated with a higher rate of MALE (hazard ratio [HR], 1.27; 95% confidence interval [CI], 1.05-1.55; P = .02) but a lower rate of all-cause death (HR, 0.80; 95% CI, 0.66-0.97; P = .02) when compared with NS status. In the OPEN group, CSs had a lower rate of all-cause death (HR, 0.74; 95% CI, 0.56-0.98; P = .04) than NSs and no significant difference in MALE (HR, 1.18; 95% CI, 0.85-1.63; P = .34). In the ENDO group, CSs had a higher rate of above-ankle amputation (HR, 1.51; 95% CI, 1.04-2.19; P = .03) and MALE (HR, 1.33; 95% CI, 1.04-1.69; P = .02). Additionally, on subset analysis of the entire cohort, it was found that, when comparing prior smokers to never-smokers, there was a 24% increase in reintervention (P = .05), and when comparing CSs to never smokers, there was a 27% increase in reintervention (P = .04). Conclusions: CSs had worse limb outcomes in the BEST-CLI trial. CSs undergoing endovascular revascularization had higher rates of MALE and above-ankle amputations following adjustment. Current smoking did not impact MALE in patients with CLTI undergoing open surgical bypass.