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Atherectomy Is Not Associated With Improved Limb-Based Outcomes Among Patients in the BEST-CLI Trial Undergoing

Caitlin W Hicks1, Alik Farber2, Gheorghe Doros3

  • 1Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.

JACC. Cardiovascular Interventions
|January 14, 2026
PubMed

Insights

In chronic limb-threatening ischemia (CLTI) patients undergoing endovascular repair, atherectomy showed similar or slightly worse limb outcomes compared to other techniques. Further analysis indicated a potential increase in major adverse limb events when atherectomy achieved technical success.

Area of Science:

  • Vascular Surgery
  • Endovascular Interventions
  • Limb Salvage Procedures

Background:

  • Atherectomy is established for coronary artery disease but its role in chronic limb-threatening ischemia (CLTI) requires further investigation.
  • Limited data exist on the efficacy of atherectomy for treating CLTI, necessitating robust clinical evidence.

Purpose of the Study:

  • To evaluate the association between atherectomy and limb-based outcomes in patients with CLTI undergoing endovascular revascularization.
  • To compare outcomes of atherectomy versus other endovascular strategies within the BEST-CLI trial.

Main Methods:

  • Analysis of patients from the prospective, randomized BEST-CLI trial who received endovascular revascularization.
  • Stratification of patients based on the use of atherectomy during the endovascular procedure.
  • Evaluation of major adverse limb events (MALE) and secondary outcomes using Kaplan-Meier and Cox proportional hazards models.

Main Results:

  • Among 923 endovascular interventions, 14.3% included atherectomy. Adjusted analyses revealed similar rates of MALE, major reintervention, amputation, and all-cause death between atherectomy and non-atherectomy groups.
  • A sensitivity analysis in patients with technical success showed atherectomy was associated with higher MALE (aHR: 1.51; 95% CI: 1.03-2.22).

Conclusions:

  • Atherectomy demonstrated similar or slightly worse limb-based outcomes compared to other endovascular technologies in CLTI patients.
  • The findings suggest caution when using atherectomy in CLTI endovascular revascularization, especially when technical success is achieved.
Abstract

Keywords:
BEST-CLIatherectomychronic limb-threatening ischemiaperipheral arterial disease

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