Background
Vascular surgery has undergone a profound transformation in the past three decades, shifting from exclusively open procedures to endovascular and hybrid approaches [1]. This evolution continues, driven by technological advances, big data [2], artificial intelligence (AI), and changing healthcare systems.
The "vascular surgeon of the future" will need to master open, endovascular, and hybrid techniques, understand new biomaterials and devices, and incorporate AI-based decision support, registries [2], and simulation into daily practice.
Endovascular Expansion
- EVAR, TEVAR, FEVAR, BEVAR [3], PMEG [4] now standard for most aneurysms [5] (see 4Aneurysms and 6Thoracic Aortic).
- Complex aortic repairs increasingly endovascular, with open reserved for select cases [6].
- SFA and iliac interventions dominated by drug-coated balloons (DCB) [7], drug-eluting stents (DES) [8], and bioresorbable scaffolds (see 10PAD) [9].
Hybrid Surgery
- Hybrid operating rooms allow simultaneous open and endovascular procedures [10].
- Examples: carotid stenting with open access [11] (see 7Carotid/7Carotid), iliac conduits for EVAR, hybrid trauma (laparotomy + embolization [12], see 16EVTM) [13].
Multidisciplinary Care
- Vascular surgery overlaps with cardiology, radiology, nephrology, oncology.
- Heart-team and vascular-team models [14] becoming standard [15].
Personalized Medicine
- Molecular profiling (e.g., AAA rupture risk, venous thrombosis genetics) [16].
- Targeted antithrombotic therapy [17] [18].
- 3D printing for patient-specific device planning.
Artificial Intelligence (AI) and Big Data
- AI-based imaging analysis: automatic plaque morphology, aneurysm growth prediction, vessel sizing [19].
- Machine learning registries: Swedvasc [20], Vascunet [2] [21], EVTM Registry [22].
- Clinical decision support systems: real-time guidance in the hybrid OR [19].
Robotics and Automation
- Robotic catheter navigation (Magellan, Corindus) → reduced radiation exposure [23].
- Robotic assistance in open/endovascular surgery under development [23].
Advanced Biomaterials
- Drug-eluting [8] and bioresorbable stents.
- Next-generation covered stents with reduced thrombosis risk [24].
- Endovascular grafts with branched/fenestrated designs [3] increasingly customizable.
Regenerative and Molecular Therapies
- Stem-cell therapies for critical limb ischemia (CLI).
- Gene therapy for arteriogenesis and angiogenesis.
- Targeted anti-inflammatory therapies in AAA [25] and atherosclerosis [26].
Wearables and Remote Monitoring
- Smart compression garments with pressure sensors.
- Telemedicine for wound/ulcer care follow-up.
- Continuous BP and perfusion monitoring in vascular patients.
Education and Simulation
- Virtual reality (VR) and augmented reality (AR) for training and intraoperative guidance.
- 3D printed models for preoperative rehearsal (complex EVAR, FEVAR, trauma).
- AI-driven simulators for continuous skill assessment.
Global and Societal Aspects
- Aging population: vascular disease burden increasing worldwide [27].
- Global disparities: limited access to endovascular technology in LMICs (low- and middle-income countries) [28].
- Sustainability: device reuse, cost-effective strategies, minimizing carbon footprint of vascular surgery.
Future Paradigms
- Total endovascular aortic surgery as default [29].
- 16EVTM fully integrated into trauma care worldwide [13] [30].
- Hybrid vascular surgeon (open + endovascular + AI skills) as the new standard [1].
- Predictive vascular medicine using AI + genomics [19].
- Expanded use of minimally invasive devices even in emergency/field conditions [31] [30].
References
- Patel VI, et al. Evolution of vascular surgery into an endovascular specialty. J Vasc Surg. 2017. PubMed
- Powell JT, et al. Endovascular vs open repair of 4Aneurysms – long-term results. NEJM. 2010. PubMed [32]
- Wanhainen A, et al. ESVS Guidelines on 4Aneurysms. Eur J Vasc Endovasc Surg. 2019. PubMed [29]
- Björck M, et al. ESVS 2025 Guidelines on Mesenteric and Renal Arteries. Eur J Vasc Endovasc Surg. 2025. PubMed [33]
- Hörer TM, et al. 16EVTM paradigm in trauma and resuscitation. J Trauma Acute Care Surg. 2016. PubMed [13]
- Mouawad NJ, et al. The role of robotics in vascular surgery. Vascular. 2020. PubMed [23]
- Conte MS, et al. Global vascular guidelines on chronic limb-threatening ischemia. J Vasc Surg. 2019. PubMed [14]
- Mani K, et al. The role of registries in vascular surgery (Swedvasc, Vascunet). Eur J Vasc Endovasc Surg. 2020. PubMed [2]
- Daye D, Walker TG. Novel endovascular devices for peripheral interventions. Tech Vasc Interv Radiol. 2018. PubMed [24]
- Loftus IM, et al. Future challenges in vascular surgery: global and societal perspectives. Br J Surg. 2021. PubMed