{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,13]],"date-time":"2026-10-13T22:37:29Z","timestamp":1791931049755,"version":"4.3.4"},"reference-count":24,"publisher":"Oxford University Press (OUP)","issue":"7","license":[{"start":{"date-parts":[[2026,6,2]],"date-time":"2026-06-02T00:00:00Z","timestamp":1780358400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/academic.oup.com\/pages\/standard-publication-reuse-rights"}],"funder":[{"DOI":"10.13039\/100000049","name":"National Institute on Aging","doi-asserted-by":"publisher","id":[{"id":"10.13039\/100000049","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100000002","name":"National Institutes of Health","doi-asserted-by":"publisher","award":["R01AG071809"],"award-info":[{"award-number":["R01AG071809"]}],"id":[{"id":"10.13039\/100000002","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100000002","name":"National Institutes of Health","doi-asserted-by":"publisher","award":["K24AG073527"],"award-info":[{"award-number":["K24AG073527"]}],"id":[{"id":"10.13039\/100000002","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2026,7,2]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Frailty is associated with mortality and adverse outcomes in chronic limb-threatening ischaemia (CLTI). Although prompt revascularization is recommended to reduce major adverse limb events (MALE), it is unclear whether frailty modifies the relative effectiveness of surgical versus endovascular therapy. The aim of this study was to assess whether the outcomes of these strategies differ by frailty status in the BEST-CLI randomized trial.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>A frailty index (FI; 0\u20131) was constructed using a deficit-accumulation approach; severe frailty was defined as an FI \u22650.45. The primary endpoint was MALE or death, and the safety endpoint was major adverse cardiovascular events (MACE). Patients with an adequate great saphenous vein (GSV) (cohort 1) and those requiring an alternative conduit (cohort 2) were analysed separately.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Of 1830 randomized patients, the FI was calculable for 1754 patients. Severe frailty was present in 654 patients (47.6%) in cohort 1 and 187 patients (49.3%) in cohort 2 and was associated with higher MALE or death regardless of treatment. In cohort 1, surgical bypass reduced the risk of MALE or death in both severely frail patients (51.0% versus 67.2%; HR 0.68 (95% c.i. 0.55 to 0.83)) and non-severely frail patients (35.4% versus 48.2%; HR 0.68 (95% c.i. 0.54 to 0.86)) versus endovascular therapy (interaction P = 0.95). In cohort 2, outcomes were similar between treatment groups across frailty strata. No interaction was observed between frailty and treatment strategy for MACE.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>In the BEST-CLI trial, severe frailty was associated with higher MALE or death. Among patients suitable for bypass with an adequate GSV, surgical bypass was more effective than endovascular therapy irrespective of frailty status.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1093\/bjs\/znag067","type":"journal-article","created":{"date-parts":[[2026,5,31]],"date-time":"2026-05-31T11:35:26Z","timestamp":1780227326000},"source":"Crossref","is-referenced-by-count":2,"title":["Frailty and the efficacy and safety of surgical\n                    <i>versus<\/i>\n                    endovascular revascularization: post-hoc analysis of the BEST-CLI trial"],"prefix":"10.1093","volume":"113","author":[{"given":"Darae","family":"Ko","sequence":"first","affiliation":[{"name":"Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife , Harvard Medical School, Boston, Massachusetts ,","place":["USA"]},{"name":"Section of Cardiovascular Medicine, Department of Medicine, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine , Boston, Massachusetts ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6226-7195","authenticated-orcid":false,"given":"Peter T","family":"Evans","sequence":"additional","affiliation":[{"name":"Section of Cardiovascular Medicine, Department of Medicine, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine , Boston, Massachusetts ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1880-048X","authenticated-orcid":false,"given":"Chan Mi","family":"Park","sequence":"additional","affiliation":[{"name":"Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife , Harvard Medical School, Boston, Massachusetts ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bernet","family":"Kato","sequence":"additional","affiliation":[{"name":"Carelon Research , Newton, Massachusetts ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Maxwell","family":"Van Over","sequence":"additional","affiliation":[{"name":"Carelon Research , Newton, Massachusetts ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michael S","family":"Conte","sequence":"additional","affiliation":[{"name":"Divisions of Vascular and Endovascular Surgery and Adult Cardiothoracic Surgery, Heart and Vascular Center, UCSF Center for Limb Preservation and Diabetic Foot, University of California SanFrancisco , San Francisco, California ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mark","family":"Cziraky","sequence":"additional","affiliation":[{"name":"Carelon Research , Newton, Massachusetts ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sachin J","family":"Shah","sequence":"additional","affiliation":[{"name":"Division of General Internal Medicine, Massachusetts General Hospital, Harvard Medical School , Boston, Massachusetts ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ashvin N","family":"Pande","sequence":"additional","affiliation":[{"name":"Section of Cardiovascular Medicine, Department of Medicine, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine , Boston, Massachusetts ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5504-5589","authenticated-orcid":false,"given":"Naomi M","family":"Hamburg","sequence":"additional","affiliation":[{"name":"Section of Cardiovascular Medicine, Department of Medicine, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine , Boston, Massachusetts ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5633-6983","authenticated-orcid":false,"given":"Kenneth","family":"Rosenfield","sequence":"additional","affiliation":[{"name":"Section of Vascular Medicine and Intervention, Massachusetts General Hospital, Harvard Medical School , Boston, Massachusetts ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2470-7978","authenticated-orcid":false,"given":"Matthew T","family":"Menard","sequence":"additional","affiliation":[{"name":"Division of Vascular and Endovascular Surgery, Brigham and Women\u2019s Hospital, Harvard Medical School , Boston, Massachusetts ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7231-4189","authenticated-orcid":false,"given":"Alik","family":"Farber","sequence":"additional","affiliation":[{"name":"Department of Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine , Boston, Massachusetts ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dae Hyun","family":"Kim","sequence":"additional","affiliation":[{"name":"Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife , Harvard Medical School, Boston, Massachusetts ,","place":["USA"]},{"name":"Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center , Boston, Massachusetts ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2026,6,2]]},"reference":[{"key":"2026070413364429500_znag067-B1","doi-asserted-by":"crossref","first-page":"e1313","DOI":"10.1161\/CIR.0000000000001251","article-title":"2024 ACC\/AHA\/AACVPR\/APMA\/ABC\/SCAI\/SVM\/SVN\/SVS\/SIR\/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: a report of the American College of Cardiology\/American Heart Association Joint Committee on Clinical Practice Guidelines","volume":"149","author":"Gornik","year":"2024","journal-title":"Circulation"},{"key":"2026070413364429500_znag067-B2","doi-asserted-by":"crossref","first-page":"3S","DOI":"10.1016\/j.jvs.2019.02.016","article-title":"Global vascular guidelines on the management of chronic limb-threatening ischemia","volume":"69","author":"Conte","year":"2019","journal-title":"J Vasc Surg"},{"key":"2026070413364429500_znag067-B3","doi-asserted-by":"crossref","first-page":"1798","DOI":"10.1016\/S0140-6736(23)00462-2","article-title":"A vein bypass first versus a best endovascular treatment first revascularisation strategy for patients with chronic limb threatening ischaemia who required an infra-popliteal, with or without an additional more proximal infra-inguinal revascularisation procedure to restore limb perfusion (BASIL-2): an open-label, randomised, multicentre, phase 3 trial","volume":"401","author":"Bradbury","year":"2023","journal-title":"Lancet"},{"key":"2026070413364429500_znag067-B4","doi-asserted-by":"crossref","first-page":"2305","DOI":"10.1056\/NEJMoa2207899","article-title":"Surgery or endovascular therapy for chronic limb-threatening ischemia","volume":"387","author":"Farber","year":"2022","journal-title":"N Engl J Med"},{"key":"2026070413364429500_znag067-B5","doi-asserted-by":"crossref","first-page":"101748","DOI":"10.1016\/j.arr.2022.101748","article-title":"Prevalence of frailty in patients with lower extremity peripheral arterial disease: a systematic review and meta-analysis","volume":"82","author":"Wang","year":"2022","journal-title":"Ageing Res Rev"},{"key":"2026070413364429500_znag067-B6","doi-asserted-by":"crossref","first-page":"e023138","DOI":"10.1161\/JAHA.121.023138","article-title":"Association of frailty with treatment selection and long-term outcomes among patients with chronic limb-threatening ischemia","volume":"10","author":"Butala","year":"2021","journal-title":"J Am Heart Assoc"},{"key":"2026070413364429500_znag067-B7","doi-asserted-by":"crossref","first-page":"e030294","DOI":"10.1161\/JAHA.123.030294","article-title":"Prognostic value of hospital frailty risk score and clinical outcomes in patients undergoing revascularisation for critical limb-threatening ischemia","volume":"12","author":"Majmundar","year":"2023","journal-title":"J Am Heart Assoc"},{"key":"2026070413364429500_znag067-B8","doi-asserted-by":"crossref","first-page":"101656","DOI":"10.1016\/j.arr.2022.101656","article-title":"Impact of frailty on all-cause mortality or major amputation in patients with lower extremity peripheral artery disease: a meta-analysis","volume":"79","author":"Zhang","year":"2022","journal-title":"Ageing Res Rev"},{"key":"2026070413364429500_znag067-B9","doi-asserted-by":"crossref","first-page":"747","DOI":"10.1016\/j.jacc.2013.09.070","article-title":"Frailty assessment in the cardiovascular care of older adults","volume":"63","author":"Afilalo","year":"2014","journal-title":"J Am Coll Cardiol"},{"key":"2026070413364429500_znag067-B10","doi-asserted-by":"crossref","first-page":"e2242964","DOI":"10.1001\/jamanetworkopen.2022.42964","article-title":"Trends in use of oral anticoagulants in older adults with newly diagnosed atrial fibrillation, 2010-2020","volume":"5","author":"Ko","year":"2022","journal-title":"JAMA Netw Open"},{"key":"2026070413364429500_znag067-B11","author":"Biologic Specimen and Data Repository Information Coordinating Center"},{"key":"2026070413364429500_znag067-B12","doi-asserted-by":"crossref","first-page":"e003219","DOI":"10.1161\/JAHA.116.003219","article-title":"Design and rationale of the best endovascular versus best surgical therapy for patients with critical limb ischemia (BEST-CLI)","volume":"5","author":"Menard","year":"2016","journal-title":"Trial. J Am Heart Assoc"},{"key":"2026070413364429500_znag067-B13","doi-asserted-by":"crossref","first-page":"24","DOI":"10.1186\/1471-2318-8-24","article-title":"A standard procedure for creating a frailty index","volume":"8","author":"Searle","year":"2008","journal-title":"BMC Geriatr"},{"key":"2026070413364429500_znag067-B14","doi-asserted-by":"crossref","first-page":"1057","DOI":"10.1111\/jgs.17002","article-title":"Changes in a frailty index and association with mortality","volume":"69","author":"Shi","year":"2021","journal-title":"J Am Geriatr Soc"},{"key":"2026070413364429500_znag067-B15","doi-asserted-by":"crossref","first-page":"265","DOI":"10.1016\/j.jvs.2023.05.042","article-title":"Apples and oranges? A comparison of BEST-CLI to BASIL-2","volume":"78","author":"Conte","year":"2023","journal-title":"J Vasc Surg"},{"key":"2026070413364429500_znag067-B16","article-title":"\u201cTime spent at home\u201d\u2014a patient-defined outcome","author":"Sayer","year":"2016","journal-title":"NEJM Catalyst"},{"key":"2026070413364429500_znag067-B17","doi-asserted-by":"crossref","first-page":"1610","DOI":"10.1056\/NEJMp1607206","article-title":"Days spent at home\u2014a patient-centered goal and outcome","volume":"375","author":"Groff","year":"2016","journal-title":"N Engl J Med"},{"key":"2026070413364429500_znag067-B18","doi-asserted-by":"crossref","first-page":"1241","DOI":"10.1161\/CIRCULATIONAHA.123.065277","article-title":"Quality of life in patients with chronic limb-threatening ischemia treated with revascularisation","volume":"149","author":"Menard","year":"2024","journal-title":"Circulation"},{"key":"2026070413364429500_znag067-B19","doi-asserted-by":"crossref","first-page":"1570","DOI":"10.1002\/ejhf.1308","article-title":"The frailty syndrome and outcomes in the TOPCAT trial","volume":"20","author":"Sanders","year":"2018","journal-title":"Eur J Heart Fail"},{"key":"2026070413364429500_znag067-B20","doi-asserted-by":"crossref","first-page":"565","DOI":"10.1161\/CIRCULATIONAHA.123.064003","article-title":"The effect of frailty on the efficacy and safety of intensive blood pressure control: a post hoc analysis of the SPRINT trial","volume":"148","author":"Wang","year":"2023","journal-title":"Circulation"},{"key":"2026070413364429500_znag067-B21","doi-asserted-by":"crossref","first-page":"1210","DOI":"10.1161\/CIRCULATIONAHA.122.061754","article-title":"Efficacy and safety of dapagliflozin according to frailty in patients with heart failure: a prespecified analysis of the DELIVER trial","volume":"146","author":"Butt","year":"2022","journal-title":"Circulation"},{"key":"2026070413364429500_znag067-B22","doi-asserted-by":"crossref","first-page":"945","DOI":"10.1007\/s40266-024-01157-2","article-title":"Assessing frailty-specific treatment effect in cardiovascular disease: a systematic review","volume":"41","author":"Zhong","year":"2024","journal-title":"Drugs Aging"},{"key":"2026070413364429500_znag067-B23","doi-asserted-by":"crossref","first-page":"1120","DOI":"10.1093\/gerona\/glz224","article-title":"Measuring frailty in administrative claims data: comparative performance of four claims-based frailty measures in the U.S. Medicare data","volume":"75","author":"Kim","year":"2020","journal-title":"J Gerontol A Biol Sci Med Sci"},{"key":"2026070413364429500_znag067-B24","doi-asserted-by":"crossref","first-page":"897","DOI":"10.1001\/jamacardio.2023.1634","article-title":"Frailty-guided management of cardiovascular disease\u2014from clinical trials to clinical practice","volume":"8","author":"Kim","year":"2023","journal-title":"JAMA Cardiol"}],"container-title":["British Journal of Surgery"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/academic.oup.com\/bjs\/advance-article-pdf\/doi\/10.1093\/bjs\/znag067\/68449042\/znag067.pdf","content-type":"application\/pdf","content-version":"am","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/bjs\/article-pdf\/113\/7\/znag067\/68449042\/znag067.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/bjs\/article-pdf\/113\/7\/znag067\/68449042\/znag067.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,7,4]],"date-time":"2026-07-04T17:36:53Z","timestamp":1783186613000},"score":1,"resource":{"primary":{"URL":"https:\/\/academic.oup.com\/bjs\/article\/doi\/10.1093\/bjs\/znag067\/8699734"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,6,2]]},"references-count":24,"journal-issue":{"issue":"7","published-online":{"date-parts":[[2026,6,2]]},"published-print":{"date-parts":[[2026,7,2]]}},"URL":"https:\/\/doi.org\/10.1093\/bjs\/znag067","relation":{},"ISSN":["0007-1323","1365-2168"],"issn-type":[{"value":"0007-1323","type":"print"},{"value":"1365-2168","type":"electronic"}],"subject":[],"published-other":{"date-parts":[[2026,7]]},"published":{"date-parts":[[2026,6,2]]},"article-number":"znag067"}}