VESS03 - High Quality CLTI Care Requires Above Average Performance in Both Open and Endovascular Treatment

Wednesday, June 4, 2025

1:46 PM – 1:57 PM CT

Location: Morial CC, Second Floor, Room 228-230

Submitting & Presenting Author(s)

DJ

Douglas W. Jones, MD, MS

Assistant Professor
UMass Chan Medical School
Worcester, Massachusetts

Slides

Discussant(s)

Colleen P. Flanagan, MD (she/her/hers)

Vascular Surgery Integrated Resident, Clinical Informatics Fellow
UCSF
San Francisco, California

Co-Author(s)

RP

Richard J. Powell, MD

Director Heart and Vascular Center
Dartmouth-Hitchcock Medical Center
Hanover, New Hampshire
Salvatore T. Scali, MD (he/him/his)

Vascular Surgeon
University of Florida
Gainesville, Florida
Adam W. Beck, MD

Professor of Surgery
University of Alabama Medical Center
Birmingham, Alabama
PG

Philip P. Goodney, MD, MS

Attending Vascular Surgeon, Section Chief
Dartmouth Hitchcock Medical Center
Lebanon, New Hampshire
Jeffrey J. Siracuse, MD, MBA

Professor of Surgery and Radiology, Chief of Vascular and Endovascular Surgery
Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
Boston, Massachusetts
AF

Alik Farber, MD, MBA

Professor of Surgery
Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
Boston, Massachusetts
GD

Gheorghe Doros

Professor of Biostatistics
Boston University, School of Public Health, Boston, MA USA
MS

Michael B. Strong

Senior National Trial Manager
Division of Vascular and Endovascular Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
Boston, Massachusetts
KR

Kenneth Rosenfield

Section Head for Vascular Medicine and Intervention
Massachusetts General Hospital, Harvard Medical School, Boston, MA
Boston, Massachusetts
Matthew T. Menard, MD

Professor of Surgery
Division of Vascular and Endovascular Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
Lincoln, Massachusetts

Senior Author(s)

Andres Schanzer, MD (he/him/his)

Professor
UMass Chan Medical School
Worcester, Massachusetts

Objectives: The Best Endovascular versus Surgical Therapy in Patients with Chronic Limb-Threatening Ischemia (BEST-CLI) trial compared surgical bypass (open) and endovascular treatment (endo) in patients with CLTI. While center-level variation in vascular surgery outcomes is well-documented, its impact within BEST-CLI has not been explored. Moreover, traditional quality metrics often fail to adequately discriminate center-level performance. This study introduces cumulative, probability-based quality metrics—similar to those employed in professional sports (earned outcomes [EO] and wins above average [WAA])—to evaluate center-level performance in both open and endo treatment of CLTI. We hypothesized that centers excelling in both modalities would demonstrate superior overall outcomes.

Methods: Participating BEST-CLI centers were evaluated by composite Major Adverse Limb Event (MALE) or death, for all patients treated at a given site (open and endo, all BEST-CLI cohorts). WAA was calculated as a risk-adjusted, volume-sensitive measure derived from MALE/death using EO methods. Risk adjustment accounted for patient-level differences using a Cox proportional hazards model, excluding patients with incomplete data. Centers were ranked and divided into WAA quartiles from bottom (Q1) to top (Q4). Patient-level demographics and outcomes were compared across quartiles. Centers were further categorized based on WAA performance: above average (WAA>0) or below average (WAA < 0) in open, endo, or both.

Results: Analyses included 1440 patients (79% of randomized patients) treated at 146 centers. At 2-years, unadjusted MALE/Death rates varied significantly by quartile (Bottom-Q1: 58%, Q2: 43%, Q3: 33%, Top-Q4: 29%; P< 0.001)(Fig 1). Centers were evenly distributed based on WAA: both modalities above average (25%), open above average only (29%), endo above average only (21%), and both below average (25%). Among top centers (Q4), 78% achieved above average outcomes in both modalities, while 62% of bottom centers (Q1) were below average in both (Fig 2). Centers excelling in only one modality constituted 22% of top centers (5.6% open above average only, 17% endo above average only) and 38% of bottom centers (27% open above average only, 11% endo above average only).

Conclusions: MALE/death varied considerably among BEST-CLI centers, with a difference of approximately 30% seen at 2-years between bottom and top quartiles. Top-performing centers consistently achieved above average outcomes in both open and endo treatment. Conversely, centers excelling in only one modality were less likely to be top performers. These findings highlight the need for quality metrics that better differentiate center-level performance and suggest that optimal CLTI care demands proficiency in both open and endo treatment.