Can the world of vascular surgery return to the core therapeutic components of open surgery, unite them with the skillset brought by the endovascular revolution, and combine with a robotic surgery delivery system to create a third revolution in the space?
This question is part of a proposition being put forward by Alan Lumsden (Methodist DeBakey Heart and Vascular Center, Houston, USA): that robotic vascular surgery is the next great leap forward for the vascular specialty. Lumsden says only vascular surgery can add robotics to the field’s first two revolutions—open surgery and endovascular intervention—to spark a third. “With the open approach, we have a delivery system that is unacceptable, and so we have sacrificed core therapeutic efficacy for the delivery system, which is endovascular,” he told the 2025 Charing Cross (CX) Symposium (23– 25 April, London, UK), in his latest pitch from the podium as he attempts to spur colleagues to join the revolution.
“Can we use robotics to go back and maintain these core therapeutic components, albeit with a different delivery system?” he asked colleagues gathered at the meeting. “Only we can actually operate in that space and it is going to be highly differentiating for our specialty.”
“One of the secret weapons in the USA is we have 100 fellows coming out of general surgery programmes, all of whom are trained in robotics, and the problem is people like me have said, ‘Don’t worry about it, we’ve got this from an endovascular standpoint, you’re not going to need it.’ But I submit to you we need to capitalise on this.”
It’s a pitch Lumsden has been making increasingly more often in recent times. As the recently outgoing president of the Southern Association for Vascular Surgery (SAVS), he used his presidential address at the group’s 2025 annual meeting (22–25 January, St. Thomas, the US Virgin Islands), to lay out the case for robotic surgery.
Only vascular surgeons are capable of being positioned at the epicentre of open surgery, endovascular intervention and robotics, he said, “working in that space where we can integrate these things, which I think is going to allow us to be branded differently, to market us differently and will fundamentally differentiate us”, he told the SAVS gathering. Robotics are the epitome of digital surgery and are “going to change the way we practice,” Lumsden said, referencing the long-running Pumps & Pipes collaboration between Houston’s major industries, itself sparked by a conversation between Lumsden and an oilfield engineer. A lot of the solutions to vascular surgery’s problems “exist in somebody else’s toolkit,” he added.
Late last year, Lumsden also used his turn at the podium of the World Federation of Vascular Societies (WFVS) as he delivered the inaugural WFVS Roger M Greenhalgh Lecture during the 31st annual meeting of the Vascular Society of India (17–19 October 2024, Jaipur, India), to speak about the frontier-pushing topic and artificial intelligence (AI). In the lecture, entitled ‘Robotics and AI: Next revolution in vascular surgery’, the chair of cardiovascular surgery outlined a roadmap for bringing robotic vascular surgery into the fold of clinical practice. Lumsden referenced his moment of clarity around the concept, how he realised major vascular operations were being handled robotically by other specialties, and how vascular surgery must not miss the boat. He looked at ways of evaluating feasibility; selecting faculty with the necessary skillset to carry out robotic procedures; mitigating risk in getting teams up to speed; identifying high-frequency, lowrisk procedures; expanding the pool of procedures that can be performed; using training resources to test in cadavers; and obtaining US Food and Drug Administration (FDA) approval in order to obtain a vascular indication.
In London, Lumsden spoke in detail about some of the instances that led him to his moment of clarity around the role of robotics in vascular surgery. One involved a talk at a Society for Clinical Vascular Surgery (SCVS) meeting of several years prior in which Sam Money, at that time the chief of the Mayo Clinic at Scottsdale (Scottsdale, USA), was showing a robotically performed case of left renal vein transposition. But then Money made a jaw-dropping revelation: “He said, ‘I didn’t do this operation, the urologist did it.’” Lumsden told CX. Another instance went thus: Back home in Houston, Lumsden was called to assist with a bleeding complication during a pelvic procedure being carried out by a gynaecologist. When he arrived, the specialist—performing the procedure robotically—asked Lumsden if he could resolve some bleeding from an iliac artery using the robot. His response was in the negative. The gynaecologist then told him she would take care of the situation herself. “That was the low point in my career,” he said. Yet another involved an encounter with thoracic surgery, where Lumsden witnessed the robotic approach being performed on the left chest—“there was no dissection”—which had the vascular chief considering how, for him, this situation would have called upon his endovascular toolkit. The thoracic surgeon told him, “‘Alan, you guys really need to be doing this.’ I said, ‘Well, I never learned laparoscopic surgery.’ At which, he said, ‘This is not laparoscopic surgery. This is the same operation we have been doing for decades, albeit with a laparoscopic access system.’”
That’s what led Lumsden down the path of developing a robotic vascular surgery programme at Houston Methodist. The team there have gradually added more and more vascular procedures to their list of robotically performed cases, but one of the challenges in robotics, “and why it has such a bad reputation in the vascular world, is we have leapt too early to the aorta,” he said. “I would like to be Lewis Hamilton and drive an F1 car but I want to learn to drive first. We as a group of vascular surgeons are in the learning-to-drive mode. We have to ramp up, from the safe, to the much more complex as we move forward.”
Another challenge remains that the existing robotic surgery platforms currently do not have an indication for vascular, Lumsden pointed out, pondering how cases of type I and II endoleaks likely harbour “high enough volume that we can actually get an indication for doing this”.
Meanwhile, he highlighted proof of robotics’ emerging purchase in the vascular surgery world in the form of a postgraduate education course that recently took place at this year’s Society for Vascular Surgery (SVS) Vascular Annual Meeting (VAM; 4–7 June, New Orleans, USA). Led by Lumsden and his co-moderator Linda Le, also a vascular surgeon at Houston Methodist, the session heard from the likes of Money and Charudatta Bavare, who is at the vanguard of the Debakey Heart and Vascular Center’s efforts to build out its vascular robotics programme. Titled ‘Surgical robotics in vascular disease: How we can play catch up!’ it featured a debate between Lumsden and Frank Arko (Sanger Heart and Vascular Institute, Charlotte, USA) over the specialty’s future and the role of robotic vascular surgery in it.
Back in London, Lumsden sought to define where robotics enter the vascular fray. “It’s not going to be robotic, endo[vascular] or open—it’s how you bring in the imaging systems that allow us to use the endovascular skills that we have used in the past, and then how do we use some of these endovascular tools [going forward],” he explained. “It’s not going to be going away from the things we have learned, it’s how do we combine these things together, work with the smart people in the endovascular world to give us tools that can be delivered with the robot. I think it could be redefining for our specialty.”
