Table of Contents  
Year : 2020  |  Volume : 7  |  Issue : 2  |  Page : 113-115

Role of open vascular surgery in this era of endovascular interventions

Department of Vascular and Endovascular Surgery, Kauvery Hospital, Chennai, Tamil Nadu, India

Date of Submission25-May-2020
Date of Acceptance25-May-2020
Date of Web Publication17-Jun-2020

Correspondence Address:
Prof. Sekar Natarajan
18, Krishnaswamy Avenue, Luz, Mylapore, Chennai - 600 004, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijves.ijves_68_20

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How to cite this article:
Natarajan S. Role of open vascular surgery in this era of endovascular interventions. Indian J Vasc Endovasc Surg 2020;7:113-5

How to cite this URL:
Natarajan S. Role of open vascular surgery in this era of endovascular interventions. Indian J Vasc Endovasc Surg [serial online] 2020 [cited 2021 Sep 25];7:113-5. Available from:

For many years, open vascular surgery has been the gold standard for the treatment of critical limb ischemia (CLI). When the endovascular interventions were introduced, it was limited to noncalcified focal lesions. With further advances in the tools and techniques, endovascular interventions were done more liberally. Acquisition of endovascular skills by the vascular surgeons has drastically influenced the treatment patterns for lower limb peripheral arterial disease over the past two decades. With improved, lower profile devices and rapidly advancing endovascular techniques and expertise, percutaneous endovascular therapy is now performed quite frequently and in some units has become the therapy of first choice in such patients. The advocates of an endovascular- first approach note that it is less invasive, is associated with less morbidity and lower mortality, can be repeated if necessary, and allows more rapid recovery of the patient. Bypass- first proponents argue that vein bypass is more durable, results in greater and more lasting hemodynamic improvement, and is much less likely to require repetitive interventions for restenosis, especially for complex, long-segment disease. Patients are often treated on the basis of the inherent biases of those vascular specialists to whom they are referred. The decision to proceed with bypass or endovascular therapy differs widely among institutions and practitioners. Conventional surgeon-oriented end-points of success such as graft patency often have little value for the patient. An increasing focus on patient-oriented outcomes has a profound effect on surgical decision-making. Number of studies and meta-analysis of published data has shown that there is no difference in amputation-free interval between endovascular intervention and open bypass although the patency rate for bypass is higher.[1],[2] Sullivan et al.[3] reported that open surgery numbers dropped by 5% and endovascular intervention increased by 400% in 2002. Goodney et al.[4] reported that endovascular interventions increased by more than three times whereas open bypass decreased by 42% in a survey between 1996 and 2006 in the Medicare population. This disproportionate increase in the endovascular intervention was due to multiple interventions done for the same patient.

The impact of this was felt in the vascular surgical training.

With growing expertise in endovascular techniques and advances in catheter-based technology, an increasing proportion of vascular interventions are performed in an endovascular fashion. The trend has been most apparent in the treatment of abdominal aortic aneurysms (AAAs), with 78% of Medicare patients with AAA receiving aortic endografts in 2008.[5]

Such drastic fall in open aortic aneurysm repair has resulted in trainees reporting low confidence in managing these cases independently. During the past decade, there has been a three-time increase in adjudicated cases against vascular surgeons due to complications arising from open aneurysm repair cases, along with an increase in litigation against vascular surgeons in practice for fewer than 3 years.[6] A study on the impact of endovascular procedures on fellowship training in the lower extremity revascularization revealed that although the total number of lower limb bypasses fell, majority of the vascular trainees reported stable open surgery numbers. In fact, there was a disproportionate increase in common femoral endarterectomy, which could be attributed to the gradual replacement of aorto bifemoral reconstruction with hybrid common femoral endarterectomy with iliac stent/stent graft.[7] This showed that majority of the lower limb bypasses and complex procedures were being performed only in centers with vascular surgery training programs and not in the nonteaching hospitals. This leads to less experience and confidence to do open surgeries among the younger vascular surgeons. Many a times, endovascular intervention is offered for the patient not because it is indicated but because that is what they are comfortable with.

An analysis of clinical outcomes data for VSB-ABS diplomates from the Society for Vascular Surgery (SVS) Vascular Quality Initiative showed that increasing surgical experience correlated with significantly lower odds of major adverse cardiac event + post-operative death (2% lower odds/year of experience since training).[8]

Revascularization options for patients with CLI include endovascular, surgical, or the combination of both (hybrid) procedures. Uncertainty remains about the specific role of open surgery versus endovascular therapy. Currently, it is unknown whether vein bypass surgery or the best endovascular treatment (angioplasty or stenting) represents the optimal revascularization strategy in terms of amputation-free survival (AFS), overall survival, relief of symptoms, quality of life, and cost-effective use of healthcare resources.

The Bypass versus Angioplasty in Severe Ischemia of the Leg (BASIL) trial is the only randomized controlled trial to date comparing open surgical bypass with endovascular therapy for severe limb ischemia. In their initial 2005 publication, the BASIL investigators reported that the main clinical outcomes (overall survival and AFS) were no different at 2 years after randomization to angioplasty- first or bypass- first. Open surgery group showed better results beyond 2 years. When outcomes were analyzed by treatment received, patients who had received prosthetic bypass grafts (25% of the surgical arm) fared much more poorly than those treated with a vein bypass. Patients who underwent surgical bypass after an initial failed angioplasty also fared significantly worse than those who were treated initially with bypass surgery.[9]

Others have also confirmed that previous failed endovascular intervention should be predictive of poor outcome in patients undergoing open bypass surgery for CLI.[10]

Surgical bypasses provided significantly better limb salvage than endovascular intervention in patients with infrapopliteal disease and tissue loss. Surgical bypasses should be preferred in those patients unless they present with prohibitive cardiopulmonary or wound risk.[11] Similarly, for long lesions (>20 cm) in the femoral artery, despite more in-hospital stays and perioperative complications, bypass surgery has shown better results and is the procedure of choice.[12]

Thus, majority of the studies have recommended that endovascular- first approach may be advisable in patients with significant comorbidity, whereas for fit patients with a longer-term perspective, a bypass procedure may be offered as a first-line interventional treatment.[13],[14]

The early focus in clinical practice and trials has been on AFS and mortality. Although important, AFS fails to capture other end-points that are important to the patient such as persistent nonhealing wounds, recurrent hospitalization for infection, pain control, re-intervention, and impaired quality of life and the cost involved.

Many of these factors have been considered in formulating a guideline for the management of these patients. The Global Vascular Guidelines published are the most comprehensive clinical practice guidelines ever published on the management of patients with chronic limb-threatening ischemia (CLTI).[15]

Many ongoing initiatives, including the National Institutes of Health-sponsored BEST-CLI and the European BASIL II and BASIL III trials, will provide much-needed guidance regarding appropriate treatment and follow-up for patients with CLI and help address unanswered questions related to defining high-quality, cost-effective outcomes for this condition.

The BEST-CLI trial has been well designed to compare the effectiveness of open and endovascular interventions for CLTI. Most important, it was designed to account for patients with and without available, good-quality vein conduit. It has also been stratified for key clinical issues, such as tissue loss versus ischemic rest pain, as well as for anatomic factors (below-the-knee disease) that are a known influence on outcome and includes an meaningful primary end-point (major adverse limb events) that considers major re-interventions having an impact on patients.[16]

Veith while delivering the 11th John Homans Lecture to the SVS mentioned that he expects that nearly 90% of the vascular problems to be managed by endovascular means by 2026. He has said that the only role for open surgery would be limited to hybrid exposures, thoracic outlet and entrapments, failed endovascular interventions, and congenital, inflammatory, and infective arteriopathies.[17] While this may be true that majority of vascular diseases can be treated by endovascular methods, but it may not be in the best interest of the patient.

The editors of Journal of Vascular Surgery summed up regarding the standard care of CLTI. “Ability to perform both invasive treatments, endovascular procedures and open surgery, is required to appropriately treat these patients. The old adage 'when your only tool is a hammer, the whole world looks like a nail' certainly applies to the management of CLTI. Considering only one approach may reduce the likelihood of successful treatment, and it may even expose patients to ineffective or inappropriately invasive procedures. Having an autogenous saphenous vein available favors surgical bypass in advanced CLTI, while endovascular interventions are preferred for high-risk patients with less complex anatomy.”[18]

Well-trained vascular surgeons are the only ones who can provide the most appropriate, full spectrum of care for patients with vascular disease, outside the head and the heart, whether that treatment be medical, endovascular, or open. That's why we are Vascular Specialists. Otherwise, we may soon develop an artificial division among us the vascular surgeons – Interventional Vascular Surgeon and Open Vascular Surgeon. In a country like India where majority of the patients are not well to do economically and do not have insurance cover, it is imperative that we offer a solution which is longer lasting. Hence, vascular surgeons should not hesitate to offer surgery where open surgery offers better results. To quote William Mayo “The best interest of the patient is the only interest to be considered, and in order that the sick may have the benefit of advancing knowledge, union of forces is necessary.”

  References Top

Bisdas T, Borowski M, Stavroulakis K, Torsello G; CRITISCH Collaborators. Endovascular therapy versus bypass surgery as first-line treatment strategies for critical limb ischemia: Results of the interim analysis of the CRITISCH registry. JACC Cardiovasc Interv 2016;9:2557-65.  Back to cited text no. 1
Abu Dabrh AM, Steffen MW, Asi N, Undavalli C, Wang Z, Elamin MB, et al. Bypass surgery versus endovascular interventions in severe or critical limb ischemia. J Vasc Surg 2016;63:244-53.  Back to cited text no. 2
Sullivan TM, Taylor SM, Blackhurst DW, Langan EM, Cull DL, Carsten CG, et al. Has endovascular surgery reduced the number of open vascular operations performed by an established surgical practice. J Vasc Surg 2002;36:514-9.  Back to cited text no. 3
Goodney PP, Beck AW, Nagle J, Welch HG, Zwolak RM. National trends in lower extremity bypass surgery, endovascular interventions, and major amputations. J Vasc Surg 2009;50:54-60.  Back to cited text no. 4
Sachs T, Schermerhorn M, Pomposelli F, Cotterill P, O'Malley J, Landon B. Resident and fellow experiences after the introduction of endovascular aneurysm repair for abdominal aortic aneurysm. J Vasc Surg 2011;54:881-8.  Back to cited text no. 5
Desai SS, Dua A, Eidt J. Challenges in vascular surgery training: Open aneurysm repair in 2020. J Vasc Surg 2014;6 Suppl:57S-S92.  Back to cited text no. 6
Nandivada P, Lagisetty KH, Giles K, Pomposelli FB, Chaikof EL, Schermerhorn ML, et al. The impact of endovascular procedures on fellowship training in lower extremity revascularization. J Vasc Surg 2012;55:1814-20.  Back to cited text no. 7
Kraiss LW, Al-Dulaimi R, Cronenwett JL, GoodneyPP, Daniel DG, Hallett JJ, et al. Failure on a vascular surgery board-American board of surgery examination does not predict cardiovascular outcomes in the society for vascular surgery vascular quality initiative. J Vasc Surg 2020 In Press.  Back to cited text no. 8
Conte MS. Bypass versus angioplasty in severe Ischaemia of the Leg (BASIL) and the (hoped for) dawn of evidence-based treatment for advanced limb ischemia. J Vasc Surg 2010:51 Suppl:69S-75S.  Back to cited text no. 9
Spinelli F, Pipitò N, Martelli E, Benedetto F, De Caridi G, Spinelli D, et al. Endo first is not appropriate in some patients with critical limb ischemia because “bridges are burned. Ann Vasc Surg 2015;29:272-7.  Back to cited text no. 10
Lee KB, Sebastian R, Jinny LU, Ricotta JJ, Amdur R, Sidawy AN, et al. Surgical bypass has better limb salvage compared with endovascular intervention in patients with infrapopliteal occlusive disease and tissue loss. J Vasc Surg,2018: 67(6), e141–e142  Back to cited text no. 11
Zhang R, Di X, Ni L, Zeng R, Zheng Y, Liu B, et al. Endovascular intervention versus above-knee bypass surgery in femoropopliteal arterial lesion of minimum 10-cm complete occlusion. J Vasc Surg 2019;70 Suppl:193-4.  Back to cited text no. 12
Antoniou GA, Chalmers N, Georgiadis GS, Lazarides MK, Antoniou SA, Serracino-Inglott F, et al. A meta-analysis of endovascular versus surgical reconstruction of femoropopliteal arterial disease. J Vasc Surg 2013;57:242-53.  Back to cited text no. 13
Wang J, Shu C, Wu Z, Zhao J, Ma Y, Huang B, et al. Percutaneous vascular interventions versus bypass surgeries in patients with critical limb ischemia: A comprehensive meta-analysis. Ann Surg 2018;267:846-57.  Back to cited text no. 14
Conte MS, Bradbury AW, Kolh P, White JV, Dick F, Fitridge R, et al. Global vascular guideline on the management of chronic limb-threatening ischemia. J Vasc Surg 2019;69:3S-125S.  Back to cited text no. 15
Menard MT, Farber A, Assmann SF, Choudhry NK, Conte MS, Creager MA, et al. Design and rationale of the best endovascular versus best surgical therapy for patients with critical limb ischemia (BEST-CLI) trial. J Am Heart Assoc 2016;5:e003219.  Back to cited text no. 16
Frank J, Veith A. Look at the future of vascular surgery. J Vasc Surg 2016;64:885-90.  Back to cited text no. 17
Lawrence PF, Gloviczki P. Global vascular guidelines for patients with chronic limb threatening ischemia. J Vasc Surg 2019;69:1653-4.  Back to cited text no. 18


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