Atherectomy Fails to Improve Limb-Based Outcomes in Chronic Limb-Threatening Ischemia: A Critical Analysis of the BEST-CLI Trial

Introduction: The Dilemma of Chronic Limb-Threatening Ischemia

Chronic limb-threatening ischemia (CLTI) represents the most advanced and morbid stage of peripheral artery disease (PAD). Characterized by rest pain, non-healing ulcers, or gangrene, CLTI carries a high risk of major amputation and cardiovascular mortality. For clinicians, the primary goal is revascularization to restore blood flow to the affected limb, yet the optimal method—surgical bypass or endovascular therapy—has been a subject of intense debate for decades.

In recent years, endovascular techniques have seen a surge in technological advancements, including the widespread adoption of atherectomy. Atherectomy, the mechanical removal of plaque from the arterial wall, is theoretically appealing because it reduces the plaque burden and may decrease the need for high-pressure balloon angioplasty or stenting. However, while atherectomy has established roles in coronary interventions, its clinical efficacy in the peripheral vasculature—specifically for CLTI—has remained under-supported by high-quality, randomized evidence. A new analysis of the BEST-CLI trial, published in JACC: Cardiovascular Interventions, provides much-needed clarity on this controversial procedure.