Jacobs, Christopher R.

Vascular surgery has evolved from durable yet invasive open reconstructions to less traumatic endovascular techniques. While endovascular repair reduces perioperative morbidity, it introduces durability challenges and the need for lifelong surveillance. Laparoscopic surgery bridged some gaps but was hindered by steep learning curves and technical limitations. Robotic-assisted surgery represents a “third revolution”, combining the durability of open repair with the recovery and ergonomic benefits of minimally invasive approaches through enhanced 3D visualization, wristed instrumentation, and tremor filtration. This review synthesizes current evidence on robotic applications in vascular surgery, including aortic, visceral, venous, and endovascular interventions. Feasibility of robotic vascular surgery has been demonstrated in over 1500 patients across aortic, visceral, venous, and decompression procedures. Reported outcomes include pooled conversion rates of ~5%, 30-day mortality of 1–3%, and long-term patency rates exceeding 90% in aortoiliac occlusive disease. Similarly favorable outcomes have been observed in AAA repair, visceral artery aneurysm repair, IVC reconstructions, renal vein transpositions, and minimally invasive decompression procedures such as median arcuate ligament and thoracic outlet syndromes. Endovascular robotics enhances catheter navigation precision and reduces operator radiation exposure by 85–95%, with multiple series demonstrating consistent benefit compared to manual techniques. Despite these advantages, adoption is limited by high costs, lack of dedicated vascular instruments, absent haptic feedback on most platforms, and the need for standardized training. Most available evidence is observational and from high-volume centers, highlighting the need for multicenter randomized trials. Future directions include AI-enabled planning and augmented-reality navigation, which are the most feasible near-term technologies since they rely largely on software integration with existing systems. Other advances such as microsurgical robotics, soft-robotic platforms, and telesurgery remain longer-term developments requiring new hardware and regulatory pathways. Overcoming barriers through collaborative innovation, structured training, and robust evidence generation is essential for robotics to become a new standard in vascular care.

Objective: To evaluate the efficacy of regional anesthesia (RA) in enabling arteriovenous fistula (AVF) creation in patients with small-caliber veins who would typically receive arteriovenous grafts (AVG), and to compare access outcomes between AVF and AVG cohorts. Methods: We conducted a retrospective analysis of a prospectively maintained database from 2018 through 2024 involving patients with chronic kidney disease (CKD) requiring access creation. Eligible patients were those aged 18 years or older with inadequate veins for AVF creation based on initial ultrasound vein mapping. All patients underwent RA prior to the access creation and had a repeated intraoperative vein mapping at least 30 min after RA. Patients whose veins were sufficiently dilated and met the criteria for AVF creation underwent AVF formation; otherwise, an AVG was created. Outcomes included access maturation, patency rates, access failure, abandonment, and mortality. Statistical analysis was performed using R software, with significance set at p < 0.05. Results: Of the 106 patients, 67 (63.2%) underwent AVF creation post-RA due to sufficient vein dilation, while 39 (36.8%) received AVGs. Baseline vein diameters and comorbidities were comparable between groups. AVF maturation was achieved in 83.6% of AVF patients, with longer times to successful cannulation compared to AVG (median 187.0 vs 80.0 days, p = 0.037). Kaplan-Meier analysis revealed no difference in primary patency ( p = 0.97), but AVF patients had superior primary assisted ( p = 0.015) and secondary patency ( p = 0.033), and lower access failure rates ( p = 0.034) compared to AVG patients. Access abandonment and mortality rates did not differ significantly between groups. Conclusions: RA-induced venodilation enables the use of veins previously deemed inadequate for AVF creation, leading to improved access outcomes compared to AVG placement. Implementing RA may increase AVF utilization and enhance patient outcomes in hemodialysis access surgery.

We present an 81-year-old male with an extensive past medical history and an enlarging abdominal aortic aneurysm (AAA). Axial imaging showed dense aortoiliac calcification with a complete occlusion of the right common iliac and high-grade stenosis of the left common iliac artery (CIA). Shockwave Intravascular Lithotripsy and the pave-and-crack technique utilizing an endoconduit were used to dilate the left external iliac artery and the CIA to facilitate placement of an aortic stent graft and exclude the patient’s AAA. This method gives surgeons the ability to treat patients with AAAs endovascularly, despite a heavily diseased and/or diminutive iliac anatomy. We also present a contemporary literature review of the utilization of the pave-and-crack technique as well as tips and tricks of how we do it.

The ability of bone to respond to increased loading as a function of age was tested by use of three-point bending and histomorphometry. The hindlimbs of male Fischer 344 rats of three age groups (young = 4 mo, adult = 12 mo, and old = 22 mo; n = 10 per age group) were progressively overloaded by training the rats to depress a lever high on the side of a cage while wearing a weighted backpack. This squatlike movement required full extension of the hindlimbs. Exercised (Exer) rats performed 50 repetitions three times per week for 9 wk. Pack weight was gradually increased to 65% of body weight. Controls ( n = 10 per age group) performed the same exercise without additional weight. Neither the mechanical properties of the femur nor histomorphometry in the proximal tibia was significantly affected in young or adult rats. However, old Exer rats were found to have significantly smaller medullary areas and a decreased trabecular spacing than their age-matched controls. These results suggest a greater sensitivity to increased loading in aged rats.

The effect of aging on long bone mechanical properties and bone formative capacity was characterized in the male Fisher 344 rat. The femurs of rats from three age groups (4 mo., 12 mo. and 28 mo.) were tested in three-point bending to determine their structural properties. The apparent material properties were then calculated by adjusting for bone geometry. Bone formation was assessed by dynamic histomorphometry of both cortical and cancellous bone as well as by Northern blot analysis for the expression of the osteoblast phenotypic proteins osteopontin (OP), osteocalcin (OC), type I collagen (COL) and alkaline phosphatase (AP). Aging resulted in a decline in the apparent material properties that was associated with a compensatory alteration of bone geometry that preserved structural strength and stiffness. Histomorphometric analysis revealed significant age-related decreases in cancellous bone volume, trabecular number and increased trabecular separation suggesting the existence of senile osteopenia in the proximal tibia of the male Fisher 344 rat. A significant decline in bone formation rate (BFR), but not mineral apposition rate, suggests that a reduction in osteoblast number, but not osteoblast activity, contributes to age-related bone loss. The decline in BFR with aging was reflected in a decreased mRNA expression for OP, OC and COL but not AP. Further, the pattern of mRNA expression was consistent with reduced osteoblast differentiation with aging. The present study indicates the age-related decline in material properties of long bones is paralleled by a decrease in osteogenesis.