Vascular News is pleased to announce Adam Talbot (Manchester, UK) as its new Launch Pad columnist, taking over from Sarah Sillito. In his first column, Talbot writes about “reframing success” in vascular surgery and embracing the increasingly palliative aspect of the specialty.
Vascular surgery has long been associated with technically complex procedures and life-saving interventions. Yet, increasingly, we find ourselves operating in a very different context: not to prolong life, but to improve its quality, often in patients nearing the end of life. This shift invites an important question: is some vascular surgery essentially palliative?
Our patient population is ageing. Many are multi-morbid, frail, and have limited physiological reserve. Conditions like chronic limb-threatening ischaemia (CLTI), nonhealing ulcers, or aneurysmal disease often present in those with significant cardiac disease, chronic kidney disease, diabetes, frailty and cognitive decline. For these patients, the goal of surgery is rarely curative. In fact, traditional markers of success, patency rates, survival curves, limb salvage, may be less relevant than symptom relief, functional independence, and comfort.
Take, for example, the patient with severe CLTI and rest pain who is non-ambulatory, housebound, and has a limited prognosis. In such a case, an endovascular procedure to relieve pain may meaningfully improve their quality of life, even if the intervention offers only temporary benefit. Similarly, a major amputation in a nonreconstructible limb may be a pragmatic, palliative choice, trading weeks of pain and repeated debridement for comfort and dignity. These decisions are goal-oriented, not anatomy-driven.
Yet just as often, the right decision is to offer no intervention at all. As vascular surgeons, trained to ‘fix’ problems, this can feel counterintuitive. But when the burden of treatment outweighs potential benefit, non-operative management is not failure, it is compassionate care. For the frail patient with an asymptomatic abdominal aortic aneurysm (AAA), or the bed-bound individual with ischaemic rest pain unfit for anaesthesia, surgery may not align with their best interests. In these cases, conservative management, good analgesia, and support from palliative care teams may be the most appropriate path.
This space between ‘curative’ and ‘palliative’ care is complex. It demands careful shared decision-making, honest conversations about prognosis, and a willingness to challenge surgical reflexes. We must recognise that the patient’s priorities, whether relief of pain, maintenance of independence, or simply time with family, may not align with our instinct to intervene.
Importantly, this doesn’t mean abandoning vascular surgery’s technical advances or becoming nihilistic. Rather, it means reframing success. A well-judged, minimally invasive procedure that enables a patient to walk painfree for their final months can be just as valuable as a complex bypass graft. A decision to forego surgery and support a patient through natural decline, when made thoughtfully and collaboratively, can also be a success.
As vascular surgeons, we are increasingly operating in the realm of palliative surgery, whether we label it as such or not. Embracing this role doesn’t diminish our specialty; it expands it. It reminds us that our ultimate goal is not just to extend life, but to improve it.
Adam Talbot is a specialty trainee in vascular surgery based in Manchester, UK, and education representative for the Rouleaux Club—the vascular trainees’ association for Great Britain and Ireland.
I tell this to people all the time. Completely agree with the thoughts in this article and make my decisions in conjunction with patient and family goals. Thank you dor writing this.