Textbook/Part 7/Chapter 20

Future Directions in Vascular Surgery

Emerging technologies, AI applications, and future directions in vascular surgery

13 sections
47 references
Last updated today

Background

Vascular surgery has undergone a profound transformation in the past three decades, shifting from exclusively open procedures to endovascular and hybrid approaches (Mills 2008)📄. This evolution continues, driven by technological advances, big data (Mani 2020)📄, 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 (Mani 2020)📄, and simulation into daily practice.

Endovascular Expansion

Hybrid Surgery

  • Hybrid operating rooms allow simultaneous open and endovascular procedures (Bisdas 2013)📄.
  • Examples: carotid stenting with open access (Malas 2019)📄 (see 7Carotid/7Carotid), iliac conduits for endovascular aneurysm repair (EVAR), and hybrid trauma management (laparotomy + embolization (Coccolini 2017)📄, see 16EVTM) [13]📄. Resuscitative endovascular balloon occlusion of the aorta (REBOA) may be utilized in these settings as a bridge to definitive surgical control (Caicedo 2022).

Multidisciplinary Care

  • Vascular surgery overlaps with cardiology, radiology, nephrology, and oncology.
  • Heart-team and vascular-team models (Conte 2019)📄 are becoming standard for complex decision-making (Neumann 2018)📄.
  • For aortic disease, a Multidisciplinary Aortic Team (MAT) is recommended to optimize outcomes in the management of complex thoracic and abdominal aortic pathology (Isselbacher 2022).
  • Integrated care models also extend to the management of common comorbidities, such as atrial fibrillation (AFib), where shared decision-making across specialties is essential for stroke prevention and perioperative management (Writing Committee 2022).

Personalized Medicine

  • Molecular profiling (e.g., abdominal aortic aneurysm (AAA) rupture risk, venous thrombosis genetics) (Sakalihasan 2018) and the application of polygenic risk scores (PRS) for cardiovascular disease (CVD) risk assessment [20].
  • Integration of biomarkers and social determinants of health (SDoH) to refine risk stratification in atherosclerotic arterial diseases (Scalise 2025).
  • Targeted antithrombotic therapy (Eikelboom 2017)📄 (Bonaca 2020)📄.
  • 3D printing for patient-specific device planning.

Artificial Intelligence (AI) and Big Data

Robotics and Automation

  • Robotic catheter navigation (Magellan, Corindus) → reduced radiation exposure (Mouawad 2020)📄.
  • Robotic assistance in open/endovascular surgery under development (Mouawad 2020)📄.
  • Machine learning (ML) integration for 2D/3D registration enhances the precision of image-guided interventions and automated navigation systems (Unberath 2021).

Advanced Biomaterials

  • Drug-eluting stents (DES) (Dake 2011)📄 and bioresorbable stents.
  • Next-generation covered stents with reduced thrombosis risk (Daye 2018).
  • Endovascular grafts with branched or fenestrated designs (Oderich 2017)📄 that are increasingly customizable.
  • Advanced porous biomaterials engineered with specific architectural features to optimize tissue-specific biocompatibility and promote cellular integration (Hernandez 2022).

Regenerative and Molecular Therapies

  • Stem-cell therapies for critical limb ischemia (CLI).
  • Gene therapy for arteriogenesis and angiogenesis.
  • Targeted anti-inflammatory therapies in abdominal aortic aneurysm (AAA) (Golledge 2017)📄 and atherosclerosis (Libby 2021).

Wearables and Remote Monitoring

Wearable activity monitors (WAM) have emerged as a critical tool in home-based exercise therapy (HBET) for patients with peripheral arterial disease (PAD) and intermittent claudication (IC), providing objective data to support supervised or self-directed walking programs (Chan 2021). Digital interventions, including wearables and smartphone applications, are effective in promoting physical activity, although considerations regarding socioeconomic status are necessary to ensure equitable access and efficacy (Western 2021).

  • Smart compression garments with pressure sensors.
  • Telemedicine for wound/ulcer care follow-up.
  • Continuous blood pressure (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 endovascular aneurysm repair (EVAR), FEVAR, trauma).
  • AI-driven simulators for continuous skill assessment.

Global and Societal Aspects

  • Aging population: vascular disease burden increasing worldwide, with cardiovascular disease remaining the leading cause of death globally (GBD 2019)📄,(Martin 2024).
  • Global disparities: limited access to endovascular technology in low- and middle-income countries (LMICs) (Bencheikh 2023). The rising prevalence of type 2 diabetes (T2D) in these regions presents a significant societal challenge, requiring integrated management strategies to mitigate long-term vascular complications (Davies 2022).
  • Sustainability: device reuse, cost-effective strategies, minimizing carbon footprint of vascular surgery.

Future Paradigms

References

  1. Patel VI, et al. Evolution of vascular surgery into an endovascular specialty. J Vasc Surg. 2017. PubMed
  2. Powell JT, et al. Endovascular vs open repair of 4Aneurysms – long-term results. NEJM. 2010. PubMed (Powell 2010)
  3. Wanhainen A, et al. ESVS Guidelines on 4Aneurysms. Eur J Vasc Endovasc Surg. 2019. PubMed (Wanhainen 2019)📄
  4. Björck M, et al. ESVS 2025 Guidelines on Mesenteric and Renal Arteries. Eur J Vasc Endovasc Surg. 2025. PubMed (Wahlgren 2025)
  5. Hörer TM, et al. 16EVTM paradigm in trauma and resuscitation. J Trauma Acute Care Surg. 2016. PubMed [13]📄
  6. Mouawad NJ, et al. The role of robotics in vascular surgery. Vascular. 2020. PubMed (Mouawad 2020)📄
  7. Conte MS, et al. Global vascular guidelines on chronic limb-threatening ischemia. J Vasc Surg. 2019. PubMed (Conte 2019)📄
  8. Mani K, et al. The role of registries in vascular surgery (Swedvasc, Vascunet). Eur J Vasc Endovasc Surg. 2020. PubMed (Mani 2020)📄
  9. Daye D, Walker TG. Novel endovascular devices for peripheral interventions. Tech Vasc Interv Radiol. 2018. PubMed (Daye 2018)
  10. Loftus IM, et al. Future challenges in vascular surgery: global and societal perspectives. Br J Surg. 2021. PubMed
  11. Isselbacher EM, et al. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease. Circulation. 2022. PubMed (Isselbacher 2022)

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