^ COMMENTARY ——————————————————————————————— ^ On the Silver Jubilee of Subintimal Angioplasty, How Successful Are Contemporary Endovascular Therapies in the Management of Critical Limb Ischemia? Sherif Sultan, MD, FRCS, EBQS-VASC, FEBVS, 1,2 and Niamh Hynes, MRCS 1 Western Vascular Institute, Department of Vascular and Endovascular Surgery, Galway University Hospital, Galway, Ireland. 2 Department of Vascular and Endovascular Surgery, Galway Clinic, Doughiska, Galway, Ireland. We congratulate Soga et al. 1 in this issue of the JEVT on the substantial amount of work involved in collecting and analyzing data on 1053 patients from 14 national centers. This is no mean feat. The appetite for catheter-based revascularization therapies over recent years has been fueled by a number of factors, not least of which is patient choice. Other ele- ments contributing to this endovascular drive include technical advancements, an aging population, worsening comorbid patient sta- tus, and reduction in the costs associated with endovascular devices. However, although patient choice may be biased by a subjective fear of open surgical techniques and a lack of understanding of the clinical applications of newer technologies, it is incumbent upon us as professionals to find objective evidence that assists us in making informed clinical decisions that will enable us to offer the most appropriate treatment to our patient based on robust clinical parameters. Many articles have been published documenting the equivalence of endovascular and surgical techniques, even in the case of critical limb ischemia (CLI). What are lacking are objective decision- making tools that will inform our choice between endovascular and surgical treatment options, and Soga et al. did not update us on this decision process. From reading their article, one could come to the conclusion that good surgeons should perform bypass pro- cedures and those proficient in endovascular techniques should undertake catheter-based revascularization. However, the decision pro- cess is not this simple, and where does that leave those vascular surgeons who have commendable experience in both surgical and endovascular techniques? Randomized controlled trials have been just as inefficient in answering this elusive ques- tion. In the BASIL trial (Bypass versus Angio- plasty in Severe Ischemia of the Leg), 50% of all patients did not have access to any sort of vascular imaging and were offered primary amputation; of the 39% who were offered revascularization, morbidity was exorbitantly high at 70%, which does not represent contemporary vascular practice. 2 The equiva- lence in quality of life outcomes between the trial groups was tempered by an increase in costs at 1-year follow-up in the surgery-first group, permitting the authors to recommend a percutaneous intervention–first strategy as the optimal management in patients who are candidates for either surgery or endovascular intervention. However, in making this recom- mendation, the authors did not factor in the Invited commentaries published in the Journal of Endovascular Therapy reflect the opinions of the author(s) and do not necessarily represent the views of the Journal or the INTERNATIONAL SOCIETY OF ENDOVASCULAR SPECIALISTS. The authors declare no association with any individual, company, or organization having a vested interest in the subject matter/products mentioned in this article. Corresponding author: Mr. Sherif Sultan, MD, FRCS, EBQS-VASC, FEBVS, Consultant Vascular and Endovascular Surgeon, Western Vascular Institute, Department of Vascular and Endovascular Surgery, University College Hospital, Galway, Newcastle Road, Galway, Ireland. E-mail: sherif.sultan@hse.ie 254 J ENDOVASC THER 2014;21:254–257 Q 2014 by the INTERNATIONAL SOCIETY OF ENDOVASCULAR SPECIALISTS Available at www.jevt.org