Search Results (32)

(1) Background: Comparison of clinical outcomes between patients with moderate-severe aortic valve stenosis and those with mild or no aortic valve stenosis undergoing surgical revascularization for critical limb threating ischemia (CLTI). (2) Methods: Single center retrospective analysis of consecutive patients undergoing surgical lower limb revascularization with femoro-distal bypass for critical ischemia between 2016 and 2022. All patients were evaluated preoperatively by echocardiographic examination and divided into two cohorts: group A with moderate-severe aortic valve stenosis (AVA-cm² < or =1.5 cm²) and group B with mild or absent stenosis (AVA-cm² > 1.5 cm²). Primary outcomes were major limb amputation and mortality between the two groups. The rate of major cardiovascular events (stroke, myocardial infarction, sudden cardiac death) and change in “preoperative functional status” were the secondary outcomes. Descriptive statistics for continuous variables were performed by calculating means, standard deviation (SD) medians, and interquartile range (IQR) while, for categorical variables, frequencies and percentages were performed. Intergroup comparison tests, for continuous variables, were performed by t-test or corresponding nonparametric tests (Mann-Whitney test) while, for categorical variables, Chi-square test was used. Evaluation of cut-offs for the variable AVA-fx-cm², in terms of predictive of outcome outcomes, was calculated by ROC curves. Comparison between clinical and outcome variables was performed using logistic regression models. A total of 316 patients were analyzed and divided in two groups: 50 (16%) patients with moderate or severe aortic valve stenosis (group A) and 266 (84%) with no or mild aortic valve stenosis (AVA > 1.5 cm²). Patients in group A were significantly older than those in group B (78 years vs. 74 years, p value = 0.005); no other significant comorbidity differences were found between the two groups. The mean follow-up was 1178 days (SD 991 days; 2–3869 days). There were no statistically significant differences between group A and group B in terms of major amputation rate (20% vs. 16.5%; p = 0.895) and overall mortality (48.0% vs. 40.6%; p = 0.640). In the total cohort, the statistically significant variables associated with the major amputation were systemic perioperative complication (OR 5.83, 95% CI: 2.36, 14.57, p < 0.001), bypass-related complication within 30 days of surgery (OR 2.74, 95% CI: 1.17, 6.45, p = 0.020), surgical revascularization below the knee (OR 7.72, 95% CI: 1.53, 140.68, p = 0.049), and the presence of a previous cardiovascular event (OR 2.65, 95% CI: 1.14, 6.26, p = 0.024). In patients undergoing surgical revascularization for CLTI, no significant difference in major amputation rate and overall mortality was found between subjects with mild or no aortic valve stenosis and those with moderate/severe stenosis. As expected, overall mortality was higher in older patients with worse functional status. A significantly higher rate of limb amputation was found in those subjects undergoing subgenicular revascularization, early bypass failure, or previous cardiovascular event. Full article

Background/Objectives: Peripheral artery disease (PAD) impacts more than 200 million individuals globally and leads to mortality and morbidity secondary to progressive limb dysfunction and amputation. However, clinical management of PAD remains suboptimal, in part because of the lack of standardized biomarkers to predict patient outcomes. Growth differentiation factor 15 (GDF15) is a stress-responsive cytokine that has been studied extensively in cardiovascular disease, but its investigation in PAD remains limited. This study aimed to use explainable statistical and machine learning methods to assess the prognostic value of GDF15 for limb outcomes in patients with PAD. Methods: This prognostic investigation was carried out using a prospectively enrolled cohort comprising 454 patients diagnosed with PAD. At baseline, plasma GDF15 levels were measured using a validated multiplex immunoassay. Participants were monitored over a two-year period to assess the occurrence of major adverse limb events (MALE), a composite outcome encompassing major lower extremity amputation, need for open/endovascular revascularization, or acute limb ischemia. An Extreme Gradient Boosting (XGBoost) model was trained to predict 2-year MALE using 10-fold cross-validation, incorporating GDF15 levels along with baseline variables. Model performance was primarily evaluated using the area under the receiver operating characteristic curve (AUROC). Secondary model evaluation metrics were accuracy, sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV). Prediction histogram plots were generated to assess the ability of the model to discriminate between patients who develop vs. do not develop 2-year MALE. For model interpretability, SHapley Additive exPlanations (SHAP) analysis was performed to evaluate the relative contribution of each predictor to model outputs. Results: The mean age of the cohort was 71 (SD 10) years, with 31% (n = 139) being female. Over the two-year follow-up period, 157 patients (34.6%) experienced MALE. The XGBoost model incorporating plasma GDF15 levels and demographic/clinical features achieved excellent performance for predicting 2-year MALE in PAD patients: AUROC 0.84, accuracy 83.5%, sensitivity 83.6%, specificity 83.7%, PPV 87.3%, and NPV 86.2%. The prediction probability histogram for the XGBoost model demonstrated clear separation for patients who developed vs. did not develop 2-year MALE, indicating strong discrimination ability. SHAP analysis showed that GDF15 was the strongest predictive feature for 2-year MALE, followed by age, smoking status, and other cardiovascular comorbidities, highlighting its clinical relevance. Conclusions: Using explainable statistical and machine learning methods, we demonstrated that plasma GDF15 levels have important prognostic value for 2-year MALE in patients with PAD. By integrating clinical variables with GDF15 levels, our machine learning model can support early identification of PAD patients at elevated risk for adverse limb events, facilitating timely referral to vascular specialists and aiding in decisions regarding the aggressiveness of medical/surgical treatment. This precision medicine approach based on a biomarker-guided prognostication algorithm offers a promising strategy for improving limb outcomes in individuals with PAD. Full article

Surgical myocardial revascularization, regardless of the technique used, causes ischemia–reperfusion injury (IRI) in the myocardium mediated by inflammation and degradation of the endothelial glycocalyx (EG). We investigated the difference between on-pump and off-pump techniques in terms of the concentration of proinflammatory interleukin (IL)-18 and the EG degradation products syndecan-1 and hyaluronic acid measured by ELISA in the peripheral and cardiac circulation during open heart surgery and in the early postoperative period. The concentration of IL-18, C-reactive protein (CRP), and cardiac troponin T (cTnT) and the leukocyte count increased statistically significantly in revascularized patients at 24 and 72 h after revascularization compared to the beginning of the procedure and was always statistically significantly higher in on-pump patients. Syndecan-1 and hyaluronic acid only increased in on-pump patients 24 and 72 h after revascularization. IL-18 correlated positively with syndecan-1 and CRP only in the pump setting and with the number of leukocytes in both revascularization regimens 24 and 72 h after the surgery. cTnT and hyaluronic acid did not correlate with IL-18. Our results suggest that IL-18 plays an important role in the early inflammatory response in patients during open heart surgery and in the early postoperative period, leading to additional damage to the EG, while it is probably not responsible for myocardial necrosis. It could serve as a biomarker to identify high-risk patients and as a therapeutic target to reduce inflammation and EG degradation. In addition, measurement of IL-18 could help improve the treatment, recovery, and outcomes of patients after heart surgery. Full article

Blocked or narrowed arteries restrict blood flow to the lower limbs, commonly leading to peripheral artery disease (PAD). Patients with PAD have been shown to have increased gait variability, which may contribute to higher rates of falls and worsen functional outcomes. Surgical revascularization seeks to restore blood flow to the legs, but it is unknown if this restoration enhances limb function. This study investigated whether gait variability changes in patients with PAD after revascularization surgery. Thirty-three patients with PAD exhibiting claudication symptoms were recruited for the study. Kinematic data were recorded using a motion capture system while the patients walked on a treadmill following a progressive treadmill protocol, both before and after undergoing revascularization surgery. Angular sagittal movements’ linear and nonlinear variability in the lower limbs were measured and compared before and after surgery across the ankle, knee, and hip joints. Following revascularization surgery, knee joint sample entropy (SampEn) decreased, suggesting improved gait regularity. Furthermore, the hip range of motion (ROM) significantly decreased, whereas the knee ROM significantly increased. The ankle joint showed significantly greater changes in the Lyapunov Exponent (LyE) relative to the pre-exercise condition compared with the hip and knee joints. No significant differences existed in the linear variability (standard deviation) of the ROM between joints. In individuals with PAD, revascularization surgery considerably increased knee ROM and gait regularity, indicating improved limb function and motor control. However, the ankle ROM remained unchanged, indicating the need for targeted strengthening exercises post-surgery. Full article

Neuroprotective strategies in coronary artery interventions are essential due to the rising number of high-risk patients undergoing procedures like coronary artery bypass grafting (CABG), totally endoscopic coronary artery bypass (TECAB), and hybrid revascularization. In this review article, we summarize the neurological complications associated with coronary artery disease intervention and the risk mitigation strategies. CABG carries significant risks, including ischemic stroke, encephalopathy, seizures, and peripheral nerve injuries. Risk factors include advanced age, hypertension, diabetes, and atherosclerosis. Off-pump CABG minimizes stroke risk by avoiding aortic manipulation and CPB. TECAB and hybrid revascularization have fewer reported neurological complications but still pose risks of stroke and cranial nerve injuries. Pharmacological neuroprotection includes agents such as barbiturates, volatile anesthetics, lidocaine, NMDA receptor antagonists, magnesium, nimodipine, corticosteroids, and aprotinin. Deep hypothermic circulatory arrest (DHCA) is reserved for complex aortic cases requiring a bloodless surgical field. Intraoperative strategies involve cerebral perfusion monitoring, embolic protection devices, and therapeutic hypothermia. Preoperative optimization targets risk factors, arrhythmia prevention, and antiplatelet therapy management. Postoperatively, timely antiplatelet administration, glucose control, hemodynamic stabilization, and cognitive monitoring are critical. Comprehensive neuroprotective approaches, spanning pre- to postoperative phases, aim to reduce neurological complications and enhance outcomes in coronary interventions. Full article

Objective: Cardiopulmonary bypass (CPB) via the right axillary artery (RAA) has become an alternative perfusion strategy, especially in complex aortic procedures. This study delineates our technique and outcome with direct axillary cannulation utilizing the Seldinger technique, which we adopted as the standard perfusion strategy in the sternum-sparing minimally invasive total coronary revascularization via left anterior thoracotomy (TCRAT) using CPB. Methods: From November 2019 to December 2023, a total of 413 consecutive patients underwent nonemergent isolated coronary artery bypass grafting (CABG) via left anterior minithoracotomy on CPB with peripheral cannulation via the RAA and cardioplegic cardiac arrest, using this technique as a default strategy in the daily routine. All patients had multivessel coronary artery disease. The primary outcome was intraoperative cannulation-related complications (bleeding, revision, ischemia, wound healing complications). The secondary outcome was cannulation-related events during follow-up (blood pressure differences, incidence of brachial plexus injury, clinical signs of circulatory problems of arm and hand, re-interventions). Mean midterm follow-up was 18.7 ± 12.3 [1.1–51.2] months. During follow-up, 16 patients died. Overall, a total of 397 patients (344 male; 67.6 ± 9.7 [32–88]) were included for follow-up (100%). Results: The RAA was successfully cannulated in 100% of patients. A cannula size of 16 Fr was used in 34.6%, 18 Fr in 63.9% and 20 Fr in 1.5% of all patients. There was no intraoperative bleeding complication. In two patients, intraoperative revision of the RAA was required, necessitating a venous patch repair. At follow-up, there were no differences between the systolic and diastolic blood pressure or the pressure gradients between the right and left arm. Transient numbness of the right hand was observed in two patients. Permanent numbness was not observed. No patient needed further intervention or surgical revision of the RAA. Conclusions: The right axillary cannulation is feasible and safe in terms of vascular injury and brachial plexus injury with excellent in-hospital and follow-up outcome. Full article

Background: Medial arterial calcification (MAC), a distinct form of vascular pathology frequently coexisting with peripheral arterial disease (PAD), poses unique challenges in limb salvage among patients with diabetes, chronic kidney disease, and end-stage renal disease. This study examines the incidence of MAC and its impact on limb salvage outcomes over a decade of experience at a tertiary limb salvage center. Methods: A retrospective review of all complex lower extremity (LE) reconstructions using local flap (LF) or free tissue transfer (FTT), performed from July 2011 to September 2022, was conducted. Patients were classified into MAC and No MAC groups based on pedal radiography evaluations using the Ferraresi MAC scoring system. The primary outcomes were major lower extremity amputation (MLEA), the need for postoperative vascular intervention, major adverse limb events (MALE; defined as the composite of any unplanned reoperation, MLEA, or postoperative revascularization attempt), and mortality. Results: During the study period, a total of 430 LE reconstructions were performed with LF or FTT. A total of 323 cases (75.1%) demonstrated no MAC while the remaining 107 (24.9%) demonstrated MAC. The MAC group exhibited significantly higher rates of diabetes, PAD, and renal disease. With a follow-up duration of 17.0 (IQR: 33.9) months, the MAC group demonstrated a significantly higher rate of MLEA (24.3% vs. 13.0%, p = 0.006), postoperative vascular intervention (23.4% vs. 8.7%, p < 0.001), MALE (57.0% vs. 25.7%, p < 0.001), and mortality (28.0% vs. 9.9%, p < 0.001). Multivariate analysis identified MAC as independently predictive of MALE (OR: 1.8, CI: 1.1–3.0, p = 0.033). Conclusion: MAC is prevalent among surgical candidates for limb salvage. Patients with MAC represent a significant medical and reconstructive challenge. Radiographic screening for MAC should be considered in all limb salvage candidates with LE wounds, especially in those with diabetes and kidney disease. Assessing MAC is important for better evaluating risk factors and surgical options so as to optimize outcomes in this challenging population. Full article

Background and Objectives: We aim to evaluate the dynamics of glycemic status and markers of carbohydrate metabolism 12 months after coronary artery bypass grafting (CABG) and their relationship with the one-year prognosis. Materials and Methods: The analysis of outcomes of 653 patients during 1 year after coronary artery bypass grafting is presented. In those patients who visited the study center after 1 year, markers of carbohydrate metabolism (glucose, glycated hemoglobin, fructosamine, 1.5 anhydroglucitol) were assessed; in 371 of them, they were studied at three points—before surgery, before discharge from the hospital, and one year after surgery. The influence of these indicators on the incidence of cardiovascular events (death from any cause, myocardial infarction, stroke, repeat myocardial revascularization, surgical interventions on non-coronary arteries, amputations due to peripheral atherosclerosis, emergency hospitalizations due to cardiovascular disease, or combined endpoint [CEP]) was assessed during the year after CABG. Groups with (n = 59)/absence (n = 594) of the combined endpoint were formed and compared based on the dynamics of carbohydrate metabolism markers over the course of a year. Additionally, factors associated with the development of major adverse cardiovascular events (MACE) after CABG were assessed. Results: After 1 year, the number of patients with type 2 diabetes increased from 23.9% to 25.6% and prediabetes from 17.2% to 26.6% (p < 0.001). Among patients with diabetes mellitus, the following dynamics of carbohydrate metabolism markers were noted: a decrease in glucose levels in both groups (with or without CEP), glycated hemoglobin in the group without CEP, and fructosamine in the group with CEP. There were no differences in the intergroup comparison of all the described markers (glucose, fructosamine, glycated hemoglobin) and carbohydrate metabolism at all points. The following factors were associated with the development of MACE within a year after CABG: the presence of peripheral arterial disease, preoperative fibrinogen level, the risk of surgery according to the EuroSCORE scale, and off-pump CABG. Conclusions: In patients with diabetes mellitus one year after coronary artery bypass grafting, a decrease in glucose and glycated hemoglobin levels was noted. No differences in the dynamics of carbohydrate metabolism markers were found in the groups of patients with and without cardiovascular complications. The impact of glycated hemoglobin dynamics one year after CABG on long-term prognosis requires further research. Full article

Endovascular revascularization is a critical strategy in managing total occlusions of the femoropopliteal artery, a significant challenge in patients with peripheral artery disease (PAD). This review provides a comprehensive analysis of procedural strategies, highlighting the role of drug-coated balloons, atherectomy devices, and advanced crossing techniques like subintimal recanalization and re-entry methods. It discusses the importance of lesion-specific considerations, such as the use of atherectomy devices for un-crossable or un-dilatable lesions and the effectiveness of drug-coated balloons in reducing restenosis. Emerging techniques, including the PIERCE needle-cracking method and intravascular lithotripsy, offer novel approaches for treating heavily calcified plaques. Moreover, the review compares endovascular interventions with surgical bypass, noting that while minimally invasive techniques are preferred for high-risk patients, a hybrid approach may be optimal for selected cases. Despite advances, challenges remain regarding long-term outcomes and the management of complex calcified lesions, emphasizing the need for ongoing research and innovation in this field. Full article

Critical limb ischemia (CLI) is the most severe form of peripheral arterial disease, significantly impacting quality of life, morbidity and mortality. Common complications include severe limb pain, walking difficulties, ulcerations and limb amputations. For cases of CLI where surgical or endovascular reconstruction is not possible or fails, spinal cord stimulation (SCS) may be a treatment option. Currently, SCS is primarily prescribed as a symptomatic treatment for painful symptoms. It is used to treat intractable pain arising from various disorders, such as neuropathic pain secondary to persistent spinal pain syndrome (PSPS) and painful diabetic neuropathy. Data regarding the effect of SCS in treating CLI are varied, with the mechanism of action of vasodilatation in the peripheral microcirculatory system not yet fully understood. This review focuses on the surgical technique, new modalities of SCS, the mechanisms of action of SCS in vascular diseases and the parameters for selecting CLI patients, along with the clinical outcomes and complications. SCS is a safe and effective surgical option in selected patients with CLI, where surgical or endovascular revascularization is not feasible. Full article

Background: The prevalence of peripheral arterial disease and the number of revascularization procedures performed in symptomatic patients are steadily increasing. However, uncertainties remain regarding hemodynamic monitoring after revascularization and the prediction of clinical outcomes. This study aimed to investigate hemodynamic parameters with a focus on the microvasculature. Methods: This prospective, single-center study included 29 patients (15 with intermittent claudication [IC] and 14 with chronic limb-threatening ischemia [CLTI]). Before and after the revascularization procedure, in addition to the ankle–brachial index (ABI), microperfusion parameters, including microvascular blood flow, capillary oxygen saturation (SO₂), and relative hemoglobin content (rHb), were assessed with lightguide spectrophotometry combined with laser Doppler flowmetry using an oxygen-to-see (O2C) device in the horizontal and elevated leg positions. Results: At baseline, SO₂ in the elevated leg position was significantly lower in patients with CLTI than in those with IC (p = 0.0189), whereas the other microcirculatory parameters and ABI values were not significantly different. Patients with diabetes mellitus had a higher flow rate than those without in the horizontal leg position (p = 0.0162) but not in the elevated leg position. After successful revascularization, the flow increased immediately and significantly in both positions, whereas SO₂, rHb, and the ABI did not. Conclusions: Elevated leg SO₂ was significantly lower in CLTI than in clinically compensated peripheral arterial disease, whereas microvascular flow was a suitable surrogate parameter indicating successful revascularization. In studies using surgical or interventional revascularization procedures, noninvasive hemodynamic monitoring of the microcirculation at the foot level might be beneficial. Full article

Patients with chronic kidney disease (CKD), particularly those with end-stage renal disease (ESRD), have a high prevalence of cardiovascular disease and peripheral arterial disease (PAD). Medical treatment is mainly based on risk factor management, and the surgical approach remains the gold standard treatment in specific conditions. Heparin-mediated extracorporeal low-density lipoprotein precipitation (H.E.L.P.) apheresis is effective in reducing circulating lipoprotein, fibrinogen, inflammatory mediators and procoagulant factors, thereby reducing cardiovascular risk in patients with familial hypercholesterolemia and hypertriglyceridemia. These activities may be effective in reducing symptoms and ischemic vascular lesions even in patients with severe PAD. We reported the application of a treatment protocol with H.E.L.P. apheresis in an ESRD patient with severe PAD without clinical improvement after severe revascularization who was not suitable for further surgical approaches, despite normal LDL cholesterol and lipoprotein (a). The H.E.L.P. protocol was characterized by an intensive first phase with weekly treatments followed by a single session every 10–15 days for 6 months of treatment. The overall clinical condition, foot lesions and walking distance improved significantly after the first 2 months of treatment, and foot amputation was avoided. Here, we review the main pathogenetic mechanisms through which LDL apheresis improves microcirculation and clinical outcomes. Its wider application may represent an optimal therapeutic option for patients unresponsive to standard treatment. Full article

Background and Objectives: Patients with chronic total occlusions of the coronary arteries are either treated with PCI or referred for surgical revascularization. We analyzed the patients with chronic occluded coronary arteries that were surgically treated and aimed to describe the anatomical characteristics, revascularization rates, and in-hospital outcomes achieved with coronary artery bypass grafting. Methods: Angiographic data of 2005 patients with coronary artery disease treated in our institution between January 2005 and December 2014 were retrospectively analyzed. A total of 1111 patients with at least one coronary total occlusion were identified. We reviewed the preoperative coronary angiograms and surgical protocols to determine the presence, localization, and revascularization of coronary occlusions. We also evaluated the perioperative data and in-hospital outcomes. Results: The median age of the study population was 68 years (25th–75th percentiles, 61.0–74.0). Three-vessel disease was present in 94.8% of patients and the rest (5.8%) had a two-vessel disease. The localizations of the occlusions were as follows: 68.4% in the RCA system, 26.4% in the LAD, and 28.5% in the LCX system. Multiple occlusions were present in 22.6% of the patients. Complete coronary total occlusion revascularization was achieved in 86.1% of the patients. The overall in-hospital mortality was 2.3%. The median in-hospital stay was 14.0 days. After logistic regression analysis, age (odds ratio 3.44 [95% confidence interval, 1.81–6.53], p < 0.001, for a 10-year increase) and the presence of peripheral artery disease (odds ratio 3.32 [1.39–7.93], p = 0.007) were the only statistically significant independent predictors of in-hospital mortality. Conclusions: A high revascularization rate and favorable in-hospital outcomes are achieved with coronary artery bypass surgery in patients with multi-vessel diseases and coronary total occlusions. Older age and the presence of peripheral artery disease are independent predictors of in-hospital mortality. A long-term follow-up and the type of graft (arterial vs. venous) used would bring more useful data for this type of revascularization. Full article

Tissular hypoxia stimulates vascular morphogenesis. Vascular morphogenesis shapes the cell and, consecutively, tissue growth. The development of new blood vessels is intermediated substantially through the tyrosine kinase pathway. There are several types of receptors inferred to be located in the blood vessel structures. Vascular endothelial growth factor A (VEGF-A) is the leading protagonist of angiogenesis. VEGF-A’s interactions with its receptors VEGFR1, VEGFR2, and VEGFR3, together with disintegrin and metalloproteinase with thrombospondin motifs 1 (ADAMTS1), connective tissue growth factor (CTGF), and neuropilin-1 (NRP1), independently, are studied computationally. Peripheral artery disease (PAD), which results in tissue ischemia, is more prevalent in the senior population. Presently, medical curatives used to treat cases of PAD—antiplatelet and antithrombotic agents, statins, antihypertensive remedies with ACE (angiotensin-converting enzyme) impediments, angiotensin receptor blockers (ARB) or β- blockers, blood glucose control, and smoking cessation—are not effective. These curatives were largely established from the treatment of complaint cases of coronary disease. However, these medical curatives do not ameliorate lower limb perfusion in cases of PAD. Likewise, surgical or endovascular procedures may be ineffective in relieving symptoms. Eventually, after successful large vessel revascularization, the residual microvascular circulation may well limit the effectiveness of curatives in cases of PAD. It would thus feel rational to attempt to ameliorate perfusion in PAD by enhancing vascular rejuvenescence and function. Likewise, stimulating specific angiogenesis in these cases (PAD) can ameliorate the patient’s symptomatology. Also, the quality of life of PAD patients can be improved by developing new vasodilative and angiogenetic molecules that stimulate the tyrosine kinase pathway. In this respect, the VEGFA angiogenetic pathway was explored computationally. Docking methodologies, molecular dynamics, and computational molecular design methodologies were used. VEGFA’s interaction with its target was primarily studied. Common motifs in the vascular morphogenesis pathway are suggested using conformational energy and Riemann spaces. The results show that interaction with VEGFR2 and ADAMTS1 is pivotal in the angiogenetic process. Also, the informational content of two VEGFA complexes, VEGFR2 and ADAMTS1, is crucial in the angiogenesis process. Full article

Background: Patients presenting with critical limb-threatening ischemia (CLTI) have been increasing in number over the years. They represent a high-risk population, especially in terms of major amputation and mortality. Despite multiple guidelines concerning their management, it continues to be challenging. Decision-making between surgical and endovascular procedures should be well established, but there is still a lack of consensus concerning the best treatment strategy. The aim of this manuscript is to offer an overview of the contemporary management of CLTI patients, with a focus on the concept that evidence-based revascularization (EBR) could help surgeons to provide more appropriate treatment, avoiding improper procedures, as well as too-high-risk ones. Methods: We performed a search on MEDLINE, Embase, and Scopus from 1 January 1995 to 31 December 2022 and reviewed Global and ESVS Guidelines. A total of 150 articles were screened, but only those of high quality were considered and included in a narrative synthesis. Results: Global Vascular Guidelines have improved and standardized the way to classify and manage CLTI patients with evidence-based revascularization (EBR). Nevertheless, considering that not all patients are suitable for revascularization, a key strategy could be to stratify unfit patients by considering both clinical and non-clinical risk factors, in accordance with the concept of individual residual risk for every patient. The recent BEST-CLI trial established the superiority of autologous vein bypass graft over endovascular therapy for the revascularization of CLTI patients. However, no-option CLTI patients still represent a critical issue. Conclusions: The surgeon’s experience and skillfulness are the cornerstones of treatment and of a multidisciplinary approach. The recent BEST-CLI trial established that open surgical peripheral vascular surgery could guarantee better outcomes than the less invasive endovascular approach. Full article