Endovascular SurgeryEdit

Endovascular surgery is a subspecialty within vascular care that emphasizes minimally invasive, catheter-based treatment of diseases affecting the arteries and veins. Rather than opening the body to repair vessels from the outside, many procedures are performed through small arterial access points under imaging guidance, allowing interventions from within the vessel lumen. The field has grown rapidly over the past few decades as imaging, devices, and materials have improved, expanding the range of conditions that can be treated with less trauma and often shorter recoveries than traditional open surgery.

This article surveys the origins, indications, techniques, outcomes, and ongoing debates surrounding endovascular approaches, with attention to how practice patterns have evolved in contemporary medicine. It also notes how endovascular methods intersect with broader vascular care and how decision-making is guided by patient risk, anatomy, and available evidence.

History

The concept of repairing diseased vessels from within the circulation emerged in the mid-20th century and matured with advances in imaging, catheter technology, and materials. Percutaneous translational angioplasty, popularized in the 1970s, demonstrated that vessels could be widened without open surgery. The addition of intravascular stents in the late 1980s and 1990s further expanded what could be treated through endovascular means by scaffolding vessels and improving long-term patency. Research and device development progressed across arterial beds, including the aorta, carotid arteries, renal and peripheral arteries, and venous systems. Pioneers in the field include early catheter designers and clinicians who advanced techniques such as balloon angioplasty, stenting, and later stent grafts for aneurysm repair. See André Gruntzig for angioplasty history and Charles Dotter for early catheter-based vascular interventions. The evolution of the field is reflected in dedicated subspecialty training and increasingly standardized approaches to patient selection and perioperative care. Related topics include Vascular surgery and Endovascular aneurysm repair for abdominal aortic aneurysms.

The expansion of endovascular techniques into neurovascular and carotid territories sparked ongoing debates about indications and alternatives to open procedures. The development of carotid artery stenting, for example, accompanied trials and guideline discussions about when to pursue endovascular versus open carotid revascularization, with attention to perioperative risk profiles and long-term outcomes.

Indications and scope

Endovascular surgery covers a broad spectrum of disease processes. Common indications include:

Abdominal aortic aneurysm and thoracic aortic disease treated with endovascular aneurysm repair (EVAR) or thoracic endovascular aortic repair (TEVAR). See Abdominal aortic aneurysm and Thoracic endovascular aortic repair for related concepts.
Peripheral arterial disease requiring revascularization of the iliac, femoropopliteal, or tibial arteries to alleviate claudication or prevent limb loss. See Peripheral artery disease for general context.
Carotid artery disease where endovascular carotid stenting is considered as an alternative to carotid endarterectomy in selected patients. See Carotid artery stenting and Carotid endarterectomy for comparison.
Aortic and visceral vessel pathology, including fenestrated or custom stent grafts in complex aneurysm or dissection scenarios.
Venous interventions for deep vein thrombosis, iliac vein obstruction, and certain chronic venous diseases, where endovascular approaches can restore patency or facilitate drainage. See Venous thrombosis and Venous insufficiency for broader coverage.

Clinical decision-making in endovascular care weighs anatomy (vessel size, tortuosity, plaque morphology), patient comorbidity (cardiac, renal, pulmonary risks), and likelihood of durable repair. Devices and techniques continue to evolve, expanding options for less invasive management and enabling treatment in patients who might not tolerate open procedures.

Techniques and devices

Endovascular procedures share core elements: percutaneous or limited access, image-guided navigation, catheter-based manipulation, and targeted deployment of devices to repair or bypass diseased segments. Key components include:

Access and navigation: Often gained via the common femoral artery or radial/brachial arteries, using guidewires and sheaths to reach the target vessel. See Catheter and Guidewire for foundational terms.
Imaging and guidance: Fluoroscopy remains the standard intraoperative imaging modality, with adjuncts such as intravascular ultrasound (Intravascular ultrasound) or optical coherence tomography (OCT) to characterize vessel morphology.
Balloons and stents: Balloon angioplasty expands narrowed segments, while stents provide scaffolding. Stents come in bare-metal and drug-eluting varieties, with ongoing innovation in designs for different vessel beds. See Balloon angioplasty and Stent for core concepts.
Stent grafts and devices for aneurysm repair: Endovascular aneurysm repair uses a stent graft to exclude an aneurysm from circulation, a core component of EVAR and related approaches like TEVAR for thoracic disease. See Endovascular aneurysm repair and Thoracic endovascular aortic repair.
Atherectomy and thrombectomy: Some procedures employ atherectomy devices to debulk plaque or thrombectomy systems to remove clot, depending on lesion characteristics and goals. See Atherectomy and Thrombectomy for related terms.
Embolic protection and flow management: In certain procedures, especially within the carotid and cerebral circulation, embolic protection devices help reduce the risk of distal embolization. See Embolic protection device for more.
Perioperative considerations: Contrast administration (and the risk of nephropathy), radiation exposure, and antithrombotic management before, during, and after procedures are routine concerns. See Contrast-induced nephropathy and Antithrombotic therapy for related topics.

The choice of technique and device is highly dependent on the disease segment, anatomy, and the surgeon’s experience, as well as evolving guideline recommendations and evidence from comparative studies.

Outcomes and controversies

Endovascular approaches have transformed the landscape of vascular care, delivering benefits in selected patients but also raising questions that continue to be studied:

Efficacy and durability: In many conditions, endovascular repairs (such as EVAR for abdominal aortic aneurysm) offer lower short-term mortality and faster recovery compared with open repair. Long-term durability, need for surveillance, and potential late interventions remain important considerations, especially for younger patients or those with challenging anatomies. See Endovascular aneurysm repair for deeper discussion.
Carotid interventions: Carotid stenting provides a less invasive alternative to carotid endarterectomy in certain populations but carries different perioperative risks, including embolic events and restenosis. Trials and guidelines continue to refine patient selection and perioperative protocols. See Carotid artery stenting and Carotid endarterectomy.
Access, cost, and access to care: Endovascular therapy often requires specialized equipment and imaging, potentially impacting cost and access in various health systems. Discussions about appropriate utilization emphasize balancing early recovery against long-term outcomes and the likelihood of reintervention.
Radiation and contrast exposure: Recurrent imaging and contrast use raise concerns in patients with limited renal reserve or cumulative radiation exposure, shaping procedural planning and protective strategies. See Radiation safety in interventional radiology and Contrast-induced nephropathy.
Training and guidelines: Rapid device innovation has driven ongoing need for standardized training, credentialing, and evidence-based guidelines to ensure patient safety and consistent quality. See Vascular surgery and Guidelines in vascular interventions.

These debates are informed by randomized trials, observational studies, and real-world registry data. They reflect the broader goal of delivering effective, durable, and safe care while recognizing that individual patient factors strongly influence the optimal treatment pathway.

Training and practice

Endovascular specialists typically receive training within vascular surgery or interventional radiology pathways, combining hands-on catheter-based skills with knowledge of open surgical techniques. Certification and credentialing bodies set standards for competence in imaging interpretation, device selection, and perioperative management. Ongoing professional development, participation in multidisciplinary teams, and engagement with patient-centered outcome data help guide best practices. See Vascular surgery and Interventional radiology for related training paths.

Practice patterns vary by region and health system, influenced by patient populations, reimbursement structures, and access to technology. The field remains dynamic, with new devices, platforms, and procedural approaches expanding the range of conditions that can be treated endovascularly.