When Do I Think of a Bypass? Reframing Revascularization Decisions in CLTI

During a Wednesday afternoon session at ISET 2026, Elizabeth Genovese, MD, MS, FACS, from the University of Pennsylvania in Philadelphia, challenged the reflexive “endo-first” mindset in chronic limb-threatening ischemia and asked a more nuanced question: when should bypass be considered first—and why? Drawing on contemporary trial data, registry analyses, and real-world clinical experience, the presentation reframed bypass surgery not as a last resort, but as a durable, safe, and often underutilized option for carefully selected patients.

Dr Genovese began by acknowledging why endovascular therapy has become the default approach for many vascular specialists. Patients are increasingly complex, comorbid, and understandably drawn to minimally invasive options, while operators are more comfortable with advanced endovascular techniques. At the same time, open bypass has often been sidelined due to concerns about morbidity, conduit quality, and perceived equipoise between open and endovascular outcomes. However, she argued that these assumptions deserve re-examination in light of newer evidence, particularly from BEST-CLI.

Highlighting results from BEST-CLI Cohort 1, Dr Genovese emphasized that open surgical bypass performed with a suitable great saphenous vein is not only safe but highly effective. Thirty-day major adverse cardiovascular events were low and comparable to endovascular therapy, while long-term outcomes favored bypass, including a significant reduction in death and major adverse limb events driven by fewer reinterventions and amputations. Importantly, this benefit was observed in a population that was healthier overall but anatomically complex, with a high prevalence of infrapopliteal disease and frequent need for tibial intervention in the endovascular arm.

Dr Genovese then focused on patient selection, underscoring that bypass is not for everyone. Subgroup analyses and external data suggest that patients with end-stage renal disease, advanced age, or multiple prior interventions may not experience the same benefit. In contrast, patients with lower to moderate procedural risk, advanced anatomic complexity, and severe limb threat appeared to derive meaningful advantages from a bypass-first strategy.

Dr Genovese advocated for a “patient-first” framework that integrates patient risk, limb severity, and anatomic complexity before the first angiogram is even performed. Tools such as WIfI and GLASS were highlighted as essential for predicting mortality, technical success, and durability. In particular, advanced GLASS stage disease was associated with higher rates of endovascular failure, restenosis, and inability to cross lesions—situations where bypass should be strongly considered up front.

The consequences of failed endovascular intervention were another major focus. Multiple datasets were reviewed showing that patients who undergo bypass after prior peripheral vascular intervention often require more distal targets, non-great saphenous vein conduits, and experience higher rates of graft occlusion, reintervention, and amputation. While some of this reflects selection bias, Dr Genovese presented emerging data suggesting that failed endovascular procedures may directly compromise future bypass outcomes by damaging targets, collaterals, and worsening ischemia or wound severity.

In closing, Dr Genovese urged clinicians not to miss the opportunity to offer the most durable revascularization when it matters most. For relatively healthy patients with adequate vein conduit, severe limb threat, and advanced anatomic disease, bypass may provide superior healing, limb salvage, and long-term outcomes. Rather than defaulting to endovascular therapy, she encouraged the audience to pause, evaluate the vein, stage the limb and anatomy, and choose the intervention that best serves the patient—not just the lesion.