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Looking to the Future

Looking to the future

Vascular surgery is a multidisciplinary specialty which has evolved rapidly. There is a strong record of inventing, developing and embracing new techniques and technologies; of developing new working practices, collaborative multidisciplinary team work, and of developing new educational approaches.

  • The evidence base has been used to inform the reconfiguration of services delivering improved modern and holistic care to patients.
  • Many vascular patients are relative frail and personalising best care for the individual patient is challenging.
  • Vascular surgical care will continue to develop and innovate and the future is exciting.
  • Commission on the Future of Surgery: Vascular Surger 2018

Whilst funding of future developments with vascular surgery is outside the remit of this review, failure to recognise the reality of ongoing funding restrictions would risk offering naïve aspirations that would ultimately fail to gain traction from key funding bodies.

The following have been identified as key components when considering the future of vascular surgery:

  • Value for money - cost effectiveness ('QALYs') *
  • Improved Quality of Life - patient reported outomes ('PROMS')
  • Longevity of intervention - registries and routinely collected datasets (NVR and NCIP)
  • Efficacy in delivery, including sophisticated team working - the focus of GIRFT programmes
  • Patient factors and trends - epidemiology of vascular disease

* QoL is a measure of the perceived measure of an individual’s daily life or a measure of wellbeing


The UK population is growing and is predicted to continue to rise. Age distribution shows a persistent trend with a greater proportion of older individuals (increasing the prevalence of vascular pathology within the population). Increasing age is associated with a greater burden of peripheral vascular disease and diabetic vascular disease.

However, there currently appears to be a decreasing incidence of abdominal aortic aneurysmal disease, possibly related to reduced smoking and better medical therapies.


An evolving feature of the modern world is better access to information the disease processes and communication.

This often associated with this is a greater expectation of patients.

Public health

Government and NHS driven changes in public health such as smoking cessation, lipid lowering targets, blood pressure control and early diabetes detection have played a critical role improving the vascular health of the nation.

Looking to the future, it is highly likely that preventative measures and lifestyle changes are going to be key areas to reducing the cardiovascular vascular disease burden.

  • Public health advice that is widely adopted has major downstream effects as evidenced by changes in smoking habits.
  • Greater uptake of exercise, healthier diets etc by the general population could impact in a major positive way on the incidence obesity, diabetes and vascular health.

Organisation, Integration and Delivery

Delivery of a complex healthcare pathway to large numbers of high risk patients is challenging. Significant advances and developments led by the Vascular Society have already occurred and are outlined within the Provision of Vascular Services (POVS). POVS has driven an evolutionary organisational improvement in the proposed delivery of vascular care. It is a good example of non-disruptive innovation, demonstrating what can be achieved with an evidenced based visionary approach adopted by a national body.

The actual delivery of vascular services has been further examined in the 2018 GIRFT (Getting it right first time) report which has highlighted further areas for focus. 

  • 'Hub and spoke' models of care - POVS, GIRFT
  • Optimal populations for vascular units- POVS, GIRFT
  • Speed of access to appropriate expertise- POVS, GIRFT
  • Assessment of adequacy of care, outcome measures-

Horizon scanning


Diagnostic-disease targeting, such as abdominal aortic aneurysmal disease.

This is likely to lead to potential therapeutic genetic interventions

Gene editing techniques are currently being used for xenogenic organ growth in pigs for planned eventual use in humans. Such techniques might be applicable for vessel growth


Robotic surgery has the potential to offer less invasive procedures with shorter length of hospital stay. The caveat to this approach is the current high costs associated with robotic surgery, and the relative ease of endovascular approaches.

Biomedical engineering:

3D Printing

These techniques have the potential to assist in specific endo graft development. The combination of 3D printing and regenerative medicine may allow patient specific ‘biologic’ grafts to be developed.

Endothelial seeding

Endothelial seeding onto a 3D matrix might improve graft patency and reduce infection risk

Stem cells

Stem cell vascular regeneration including the restoration of normal vascular function and structure; the reversal of vascular senescence; and the growth of new blood vessels is already in progress and likely to become more important in the future


Artificial intelligence.

Reducing radiation dosing, better computer modelling.

Synergistic or integration of multimodal imaging such as 3D ultrasound

Point of care U/S

Fusion imaging

Software engineering to generate 3 D models of diseased circulation and plan interventions and predict outcomes

Point o f Care testing

Thrombo elastograms (TEG) represents a recent development in point of care tests for bleeding. It is likely that further tests will be developed for use either in the community or in hospital such as the ‘SmartChip’ for ischaemic and glial fibrillary acidic protein (GFAP) for traumatic brain injury


Sepsis is a cause of death of people with vascular disease, from infected lower limb wounds or implanted devices.

Surgical site infection is a cause of significant morbidity and mortality.

Novel antibiotics, implant covering or implant technology such as biologically compatible or absorbable materials need to be developed

Big data

Greater interrogation of the existing data sets in the community or using the NVD are like to inform decision planning Easier methods of data capture including standardised approach to patient information recoding electronically across NHS. Voice activated recoding to avoid repetitive writing, prompts for questions. Integrated investigation and therapy pathways allowing clinicians more time to focus on high end decision making.

  • Intelligent audit and unique device identifier NVR (Outcome Registries Platform)
  • Single uniform computerised NHS patient database
  • Integration across providers
Medical devices

Technology continues to develop rapidly and the stent options increase rapidly. Better design, novel materials and delivery systems need to match the individual patient characteristics. Recent innovations have been in clot retrieval (i.e. Penumbra) and Fusion Imaging (i.e. Cydar Medcial).

Endovascular atherectomy devices show theoretical promise but the exact technique and their role have yet to be fully defined.

Point of care testing

Thrombo elastograms (TEG) represents a recent development in point of care tests for bleeding. It is likely that further tests will be developed for use either in the community or in hospital such as the ‘SmartChip’ for ischaemic and glial fibrillary acidic protein (GFAP) for traumatic brain injury

Virtual care

There is likely to be a development of virtual care and clinics improving of patients access to expert opinion.

Remote monitoring of leg ulcers and problem wound care will be supervised in a remote fashion.

Wearables and their role in disease prevention is being explored in research.

Remote monitoring of patients eg diabetic foot using nanotechnology. Pressure and temperature sensors embedded in footwear and sending data ro remote monitoring centre via mobile phone. Subject only contacted if abnormal results

Artifical intelligence

There is an emerging role for AI in the interpretation of images and this may well be applicable to say endograft selection or even management of complex patients.

Proteomics and Metabolomics

Merging genomics and other –omics (proteomics, metabolomics) with an individual’s cardiovascular risk factors and individual circumstances should inform clinicians about diagnosis, planning of treatment efficacy of treatment and prognosis.


Novel vascular drugs are more likely either to come from cardiological and / or diabetic routes if one considers the patient numbers and relative cost margins.

Re-targeting of existing drugs in novel settings such as metformin for delaying AAA growth is a relatively inexpensive approach to existing conditions.

Combination use of drugs (such as aspirin and clopidogrel) has been used to great beneficial effect. There is emerging evidence of the use of synergistic existing drugs combinations in personalized approach to cancer treatment. It is likely that options may be suitable for vascular patients.

Innovative training


Endovascular training- virtual reality and simulated reality systems

Surgical training-individual and team based training within simulated environments

Cadaveric training is both popular and helpful for specific situations

Immersion training

Mentor via video Such as Proxime (mentor)

  • “Touch Training” before real life surgery
  • Modelling and planning interventions
Human factors

The introduction of the WHO Checklist is an example of a simple approach which reduces basic and avoidable surgical events. This approach could be further refined and developed perhaps along the lines of inter-operative checks during multidisciplinary trauma surgery


Priority setting

The VS has undertaken the first Delphi process to determine the research priority setting for vascular surgery. 

This has led to NIHR funding a greater number of vascular research studies.

Vascular research collaborative (VERN)

The Vascular Research Collaborative is beginning to gain traction with trainees both leading and participating in trials. This has been shown to be a key approach to engaging trainees with research and is likely to be important in long term support for research and innovation.

Patient and public involvement

We need to develop an expectation for patients to want to be enrolled in research and to facilitate their involvement in the design of future proposals

Patient reported outcome measures (PROMS)

A focus and work is needed in this area. Patient reported outcome measures registry could potentially inform future areas for improvement in care

Registry based research

NVR data is starting to be used to collect data for research studies. This avoids duplication of effort and will improve data quality.


Failure to recognise the reality of ongoing funding restrictions would risk offering naïve aspirations that would ultimately fail to gain traction from key funding bodies. The need to demonstrate value for money, improved QoL, longevity of intervention and efficacy in delivery are key components when considering the future of vascular surgery.

Many of the future developments in vascular surgery are likely to be generated from research. These will include clinical trials, translational research (linking basic science to bedside advances) and will also be derived from co-related specialties such as cardiology, diabetes and stroke medicine.

Innovation is a broad term that encompasses new ideas, devices, methods or ways of working. Innovation can be evolutionary (or non-disruptive), where there is a gradual stepwise development of novel approaches, or it can be disruptive. Disruptive innovation is innovation that creates completely new techniques, devices or ways of working which will tend to displace older organisational structures, workforce, processes, products, services and technologies.

The timelines involved in any innovation or major research advance is usually of the order of 8-15 years. The implication being many of the major advances that will be implemented within the next 20 years are already at an early stage of development.