From Algorithms to Personalization: 4 Vascular Surgeons on How Endovascular Advances Are Changing Arterial Care

As endovascular technology continues to reshape the way vascular surgeons’ approach acute arterial disease, experience and perspective matter more than ever. We recently talked to four leading vascular surgeons to discuss current challenges and recent advancements in arterial care:

Daniel Han, MD, vascular surgeon, Icahn School of Medicine at Mount Sinai, New York

Dejah Judelson, MD, vascular surgeon, University of Massachusetts Memorial Health

Patrick Muck, MD, FACS, vascular surgeon, TriHealth Heart & Vascular Institute, Cincinnati

Leigh Ann O’Banion, MD, FACS, FSVS, RPVI, vascular surgeon, University of California, San Francisco

In the following discussion, these surgeons reflect on the lessons they wish they’d learned earlier in their careers, the growing role of endovascular-first strategies, and how to personalize care in complex arterial disease. They address the importance of tailoring treatment strategies to individual patients, particularly in complex cases of acute limb ischemia, to improve outcomes and manage complications. From rethinking traditional treatment algorithms to managing distal emboli with modern thrombectomy tools, the conversation highlights a central principle: in acute limb ischemia, clinical decisions should always prioritize the patient — not just the lesion.

Q: What advice would you give to your younger self when it comes to treating arterial cases? What is something you wish you knew?

Dr. O’Banion: There’s so much advice that I would give to my younger self. But I think in terms of how we approach acute limb ischemia, it is just to be patient, take a patient-centric first approach, and recognize that as technology evolves, your algorithm is going to evolve. And so, adapt to technology, use the devices that you have, explore the data, and really use all the tools that you have to approach each patient, because each patient is very unique.

Dr. Judelson: I would tell myself not to fall into the trap of, “You need to get them lytics because you need to give them a little bit of time,” or, “you have to take them to the OR emergently.” You really need to think about the patient, the situation, and what is causing their acute limb. Is it a cardioembolic event? Do you need a big device to get out the clot? Or did their stents go down? And so, you need to be a little bit more delicate about removing the clot from the stents.

We so often get trained in two-way acute limb ischemia: You can do those endo. You can give them lytics for 24 to 48 hours and then bring them back to 2B [a reversible severe limb category]. You must take them into the OR open. And I don’t think that’s the case. I think you really need to look at the patient, the pathology, and the disease, and then come up with a curated plan for those patients. But I think long gone are the days of 2A [a less severe limb category] lysis first and 2B [more severe] open first, and I think we can find a way to really treat these patients as a whole, in a single index case.

Dr. Muck: Advice to my younger self would probably be to focus more on endovascular. I think without a doubt, there are benefits to the team, but more importantly, in a patient-first mentality, the benefits for endovascular are clear. It’s quicker revascularization, less worries about surgical site infections, which is the main thing, especially as the population perhaps is getting a little larger. Those incisions are more difficult to heal, and they have significant morbidity and sometimes mortality for folks. If you can prevent wound infections, that’s an absolute advantage.

Dr. Han: I would tell myself that taking a one-size-fits-all approach to acute limb ischemia is the biggest mistake. A lot of the time, the lesions are very different. You have to think about whether or not it’s an embolic event, if it’s an in situ event, how long the patient has been occluded. And a lot of the endovascular devices, as well as the open techniques you think about, are really based on what you think is happening inside the vessel. So, I think trying to not treat them all as the same, but really try to figure out what’s happening in situ in the patient’s vessel is the most important thing.

Q: What do you think is the most underrated advantage of an endovascular approach?

Dr. O’Banion: When you think about the advantages and disadvantages of endovascular intervention, a lot of times we’re thinking about the anatomic result, or the physical advantages, but what we don’t think about is patient satisfaction. And at the end of the day, we’re treating a patient, not a lesion. And so, there’s a lot to be said for getting the patient in and out of the operating room or the cath lab with just a puncture site and a band-aid and able to go home the next day. Whereas, if you’re in a position where you have to treat the patient with open surgery, now you’re talking about days in the hospital, longer recovery time, more pain. I think patient satisfaction is probably the most underrated advantage to an endovascular first approach.

Dr. Judelson: When you’re doing endo first, one of the advantages is that you get to see the pre and the post right then and there… I think it gives you a sense of security and also gives you an ability to stop when you’ve completed what you need to do to get the patient out of the danger zone that they’re in with their acute limb process.

Q: How do you handle distal emboli during thrombectomy?

Dr. Han: I think distal embolization, as much as we like to pretend it doesn’t happen, it can certainly happen. Ten years ago, our ability to chase after some of these distal emboli was very limited. You would have to put down a…catheter and put a 20 cc syringe at the end and try to aspirate things out. But now, even with careful technique, you can get distal emboli, and luckily, we have an endovascular thrombectomy platform that can help you address it. The 150 cm Lightning Bolt^® 6X with TraX™ is very good to bring you down into the tibial vessels. And you have the vessels down into the foot… in that space the CAT™ RX works remarkably well.

Dr. Muck: Handling distal embolization is a lot easier now with the Bolt 6X with TraX system. You can track down over your .014 wire at command and get down. [Many more] distal embolizations can be handled now. And in the old days, we would drop a lytic catheter and run them for 12 to 24 hours. You worry about access site hematomas, cranial hemorrhage, RP bleeds, all that. But now, the overwhelming majority of the time this can be handled with the Bolt 6X.

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