Blood flow restoration cuts pain, boosts quality of life in peripheral artery disease

When the arteries that feed blood to the legs narrow and harden, the body sends a clear message: pain. For people with peripheral artery disease, that pain can arrive during a walk around the block or strike even while sitting still. Left alone, the damage compounds. Tissue dies. Amputation becomes real. But a landmark study presented at the American Heart Association's Scientific Sessions in November 2022 offers something concrete: both surgical repair and minimally invasive procedures can substantially ease that pain and restore the ability to move through daily life without constant suffering.

Peripheral artery disease affects more than 200 million people worldwide. It happens when fatty plaque accumulates inside the arteries, narrowing the passages that carry blood from the heart to the legs and feet. Most people experience cramping or weakness when they walk. But in about one in ten cases, the blockage becomes severe enough to cause what doctors call chronic limb-threatening ischemia—pain that persists even at rest, a warning sign that tissue is beginning to die. Without intervention, amputation is often the outcome.

The BEST-CLI trial, which stands for Best Endovascular versus Best Surgical Therapy for Patients with Chronic Limb Threatening Ischemia, enrolled 1,830 patients across 150 medical centers in the United States, Canada, Italy, Finland, and New Zealand. It was the first randomized controlled trial of this scale to directly compare two treatment approaches: bypass surgery, in which surgeons create a new pathway around the blockage using either a patient's own vein or an artificial vessel, and endovascular procedures, in which doctors thread a balloon-tipped catheter into the blocked artery, inflate it to widen the passage, and insert a stent to hold it open. The trial's first phase found that bypass surgery using a patient's own leg vein produced better long-term results. But the real story emerged when researchers looked at something rarely measured in vascular disease research: how patients actually felt.

The quality-of-life analysis surveyed participants at the start of the study and at six intervals over four years. Researchers asked detailed questions about pain, daily activities, physical capability, and mental health. They used multiple validated questionnaires designed to capture different dimensions of well-being. What they found was striking: patients entered the study in poor condition. Pain was severe. Quality-of-life scores were low across every measure. But after either procedure—whether surgical bypass or endovascular intervention—pain dropped substantially and quality-of-life scores climbed. The improvement held across all assessment tools. Matthew Menard, the lead researcher and an associate professor of surgery at Harvard Medical School, noted that while bypass patients initially showed slightly better scores, possibly because they needed longer recovery time from surgery, these differences were minor and disappeared over time.

The study population reflected the real world of advanced peripheral artery disease: average age 67, 28 percent female, 72 percent white, with high rates of smoking, diabetes, and kidney disease. About 22 percent reported pain even at rest when they entered the trial. These were people for whom the disease had already begun to steal their lives. The finding that both treatment approaches could restore function and reduce suffering represents a significant shift in how the medical field thinks about this disease. For decades, PAD research focused narrowly on clinical outcomes—did the artery stay open, did the patient need another procedure, did they lose a limb. Quality of life was an afterthought. This trial suggests it should be central to how doctors and patients make treatment decisions. The work ahead involves refining which patients benefit most from which approach and ensuring that timely restoration of blood flow becomes standard practice rather than exception.