Part 7/Chapter 20/6-min read

Future Directions in Vascular Surgery

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

Edited by Tal M. Hörer MD, PhD · David T. McGreevy MD, PhD·Reviewed ·13 sections · 42 references

Background

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

Endovascular Expansion

  • endovascular aneurysm repair (EVAR), thoracic endovascular aortic repair (TEVAR), FEVAR, BEVAR , PMEG now standard for most aneurysms (see 4Aneurysms and 6Thoracic Aortic).
  • Complex aortic repairs increasingly endovascular, with open reserved for select cases .
  • SFA and iliac interventions dominated by drug-coated balloons (DCB) , drug-eluting stents (DES) , and bioresorbable scaffolds (see 10PAD) .

Hybrid Surgery

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

Multidisciplinary Care

  • Vascular surgery overlaps with cardiology, radiology, nephrology, and oncology.
  • Heart-team and vascular-team models are becoming standard for complex decision-making .
  • For aortic disease, a Multidisciplinary Aortic Team (MAT) is recommended to optimize outcomes in the management of complex thoracic and abdominal aortic pathology .
  • 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 .

Personalized Medicine

  • Molecular profiling (e.g., abdominal aortic aneurysm (AAA) rupture risk, venous thrombosis genetics) and the application of polygenic risk scores (PRS) for cardiovascular disease (CVD) risk assessment .
  • Integration of biomarkers and social determinants of health (SDoH) to refine risk stratification in atherosclerotic arterial diseases .
  • Targeted antithrombotic therapy .
  • 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 .
  • Machine learning registries: Swedvasc , Vascunet , endovascular trauma management (EVTM) Registry .
  • Clinical decision support systems: real-time guidance in the hybrid OR .

Robotics and Automation

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

Advanced Biomaterials

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

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) and atherosclerosis .

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 . 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 .

  • 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 .
  • Global disparities: limited access to endovascular technology in low- and middle-income countries (LMICs) . 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 .
  • Sustainability: device reuse, cost-effective strategies, minimizing carbon footprint of vascular surgery.

Future Paradigms

  • Total endovascular aortic surgery as default .
  • Endovascular trauma management (EVTM) fully integrated into trauma care worldwide .
  • Multidisciplinary aortic teams (MAT) and the hybrid vascular surgeon (open + endovascular + artificial intelligence (AI) skills) as the new standard for complex aortic care .
  • Predictive vascular medicine using AI + genomics .
  • Expanded use of minimally invasive devices even in emergency/field conditions .
  • Shared decision-making (SDM) as a fundamental requirement in the management of aortic disease to optimize patient-centered outcomes .

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
  3. Wanhainen A, et al. ESVS 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms. Eur J Vasc Endovasc Surg. 2024. PubMed
  4. Björck M, et al. ESVS 2025 Guidelines on Mesenteric and Renal Arteries. Eur J Vasc Endovasc Surg. 2025. PubMed
  5. Hörer TM, et al. 16EVTM paradigm in trauma and resuscitation. J Trauma Acute Care Surg. 2016. PubMed
  6. Mouawad NJ, et al. The role of robotics in vascular surgery. Vascular. 2020. PubMed
  7. Conte MS, et al. Global vascular guidelines on chronic limb-threatening ischemia. J Vasc Surg. 2019. PubMed
  8. Mani K, et al. The role of registries in vascular surgery (Swedvasc, Vascunet). Eur J Vasc Endovasc Surg. 2020. PubMed
  9. Daye D, Walker TG. Novel endovascular devices for peripheral interventions. Tech Vasc Interv Radiol. 2018. PubMed
  10. Loftus IM, et al. Future challenges in vascular surgery: global and societal perspectives. Br J Surg. 2021. PubMed
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  12. ESVS. Review of the ESVS 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms: what is new and prospects for development. 2026. PubMed

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