INTRODUCTION

The purpose of this review is to succinctly present the opportunities and the existing training programs in the specialty of vascular surgery, as they are formed in the cradle of the vast technological revolution and scientific progress we witness in the present, all from the perspective of graduate students.

We are a group of sixth year medical students of the National and Kapodistrian University of Athens, very intrigued and interested in the specialty of vascular surgery, who had the luck and privilege to complete a three moth elective course in the Vascular Unit of the 1st Department of Preparatory Surgery in “Hippoctateion” General Hospital of Athens. As a result, the interest was born to study the existing literature concerning the curriculum of the specialty in the pioneer countries in medicine, the distribution of vascular surgeons worldwide, their work satisfaction and, last but not least, the remodeling of the specialty the preceding years through the effect of technology and the future it creates for a vascular surgeon. We strongly believe that our research will be of paramount importance for our personal choice of specialty and enlighten the most suitable professional and educational road for each one.

BASIC TRAINING IN USA AND EUROPE

To present the training programs provided to a new doctor who opts for the residency of vascular surgery, we have to take a quick look back to its past in the United States. Before the period of 1960-1982 there was not specific training in vascular surgery, and the relevant procedures were a part of the cardiothoracic and general surgery. A better touch with vascular surgery practices was possible through apprenticeships with early pioneers. It was not until 1977 that the American Board of Surgery agreed to the creation of the subspecialty of vascular surgery and 1982 that the first officially qualified surgeons existed. Additionally, in the following period of 1983-2006, the credentials of a vascular surgeon required a one year dedicated vascular training, after the completion of an accredited general surgery residency (5-1 pathway), or after an accredited cardiothoracic surgery program, if the number of the vascular cases was deemed adequate. In the following years, an additional year was added, primarily for research (5-2). By that time, general and vascular surgery did not have distinct boundaries, despite the fellowship. General surgery thought to prepare surgeons for simple vascular operations, whereas the fellowship prepared for more complex ones. Still the public was unable to distinguish between a general and a vascular surgeon. The great imbalance between general and vascular training in addition to the rapidly increasing endovascular landscape, led to the creation of the specialty of vascular surgery in 2006 and novel educational programs. Currently, there are two programs, leading to dual board certification, the Independent Vascular Surgery Fellowship, consisting of 5 years of general surgery and 2 years of vascular surgery fellowship (5-2, duration 7 years) and the Early Specialization Program, consisting of the combination 4-2 (duration 6 years) accordingly. Lastly, the Integrated Vascular Residency program exists with a combination of 0-5 (5 years duration) accordingly, leading to vascular certification alone1.

On the other side of the Atlantic, specialty training in vascular surgery in Europe varies significantly by country, but it has been increasingly standardized under the influence of the European Union of Medical Specialists (UEMS) and the European Board of Vascular Surgery (EBVS). The duration is usually 5-6 years, depending on the country, with a core surgical training of 1-2 years and a dedicated vascular surgery training of 3-4 years2.

Specifically, in Greece, the total duration of residency training in vascular surgery is seven years, comprising two years in general surgery, followed by five years dedicated to the core specialty. There are seven university-affiliated hospitals, along with several other accredited institutions nationwide, which experience significant demand for residency positions, due to the high standards of healthcare and education provided. Trainees receive comprehensive exposure to both open surgical and endovascular techniques. Moreover, vascular surgeons have access to a wide range of postgraduate programs, many of which are specifically tailored to vascular surgery. These programs encompass advanced training in endovascular techniques, management and treatment of vascular surgery emergencies, vascular access for patients with end-stage renal disease, the application of vascular ultrasound in diagnosis and clinical management, as well as thrombosis and antithrombotic therapy. The academic career can be further enriched through additional postgraduate education (fellowship) or the pursuit of a doctoral degree (PhD), either within Greece or internationally3.

WORK SATISFACTION

When analyzing the general opportunities of a medical specialty, one must take into close consideration the degree of work satisfaction the physicians have. Unfortunately, according to a U.S. study including 14 surgical specialties, vascular surgeons have the second highest burnout incidence and the lowest degree of career satisfaction. At this day and age, burnout is a work-related syndrome increasingly affecting physicians and their ability to treat their patients. It has been linked to medical errors, decreased patient satisfaction and lower career longevity. The Society of Vascular Surgery Wellness Task Force conducted a survey which included 872 active vascular surgeons, using the Maslach Burnout Inventory. The percentages were concerning, with 41% of them experiencing at least one symptom of burnout, 37% having symptoms of depression last month, and 8% having considered suicide in the last 12 months. The survey showed that the factors significantly associated with burnout symptoms were the clinic work hours, the on-call frequency, the electronic medical record and documentation requirements, the work-home conflict and, last, the work-related physical pain4. Another survey was conducted relating to the physical pain of vascular surgeons6. Of the 263 total participants, 87% operate 3 or more times per week and 4 or more hours per day, while 48.4 % wear led garments daily. Pain was present in 74.7% of surgeons before beginning an operation, in 92.3% during an operation, and in 96.8% at completion. Professional satisfaction among vascular surgeons was linked to lower pain levels. Surgeons who reported being satisfied with their profession experienced less pain both before and two days after performing surgery. Despite the previous discouraging data, undoubtedly, the progress of the technology and the revolution of the artificial intelligence with the databases created, will aid the vascular surgeon both in the operating room, with less energy consuming instruments, and out, with less time-consuming documentation procedures.4,5

Comparative Distribution of Vascular Surgeons Across Five High-Income Countries

Substantial international heterogeneity exists in the density and distribution of vascular surgeons, reflecting differences in national workforce planning, postgraduate training output, and models of vascular care delivery. An analysis of five high-income countries—Greece, France, Germany, the United Kingdom, and the United States—highlights marked disparities in vascular surgeon availability.

Greece exhibits the highest workforce density, with 3.11 vascular surgeons per 100,000 inhabitants and a patient-to-surgeon ratio of approximately 1:32,1501. Germany also demonstrates relatively high capacity, with 1.89 surgeons per 100,000 and one surgeon serving every ~52,869 individuals2. The United States reports 1.14 vascular surgeons per 100,000 population, corresponding to a ratio of approximately 1:88,0723.

In contrast, France and the United Kingdom maintain considerably lower vascular surgeon densities. France records 0.73 surgeons per 100,000, with each vascular surgeon responsible for approximately 137,712 individuals4. The United Kingdom follows closely with 0.77 surgeons per 100,000 and a surgeon-to-population ratio of 1:129,3455.

A consideration arising from the observed disparities in vascular surgeon density pertains to the career decision-making process of medical students and junior doctors. In countries where the ratio of vascular surgeons per 100,000 population is disproportionately high—such as Greece—there may be growing concern among medical trainees regarding future job market saturation, limited operative exposure during training, and constrained long-term career prospects. The perception of an oversupplied specialty can deter new graduates from selecting vascular surgery as a preferred career path, regardless of interest or aptitude. This phenomenon may be further compounded by institutional bottlenecks in academic advancement or public sector employment. Consequently, highly qualified candidates may increasingly explore residency or fellowship opportunities abroad, particularly in health systems where the demand for vascular specialists is greater and long-term workforce planning is more balanced. Such migration trends could lead to a paradoxical scenario in which an initially oversupplied domestic workforce drives talent out of the country, further complicating national retention and training policies. Addressing these issues requires not only regulation of training entry points but also alignment of national workforce planning with actual procedural and population needs. (Table 1)

Over the past 15 years, vascular surgery worldwide has undergone a marked shift toward minimally invasive and endovascular management. For example, U.S. Medicare data show open abdominal aortic aneurysm (AAA) repairs fell by 76% from 2003 to 2013 while EVAR volumes nearly doubled11. Innovations such as fenestrated and branched stent grafts have expanded endovascular treatment to complex aortic and peripheral lesions, aided by advanced imaging (CT/MR angiography, duplex ultrasound) and hybrid operating rooms. Vascular residency slots in the U.S. grew from 161 to 202 between 2012 and 2022 and integrated 5year programs more than doubled from 41 to 84 positions, reflecting emphasis on endovascular skills12. In Greece, vascular surgery was established as an independent specialty in 1989 and early incorporated endovascular training. Greek vascular surgeons now perform all aortic and peripheral endovascular procedure. The 2009 financial crisis strained Greece’s health budget, however, highlighting the high cost of new endovascular devices and challenging widespread adoption of all new technologies. Overall, the past decade has seen endovascular and percutaneous approaches become the main choice for many vascular conditions, with open surgery reserved increasingly for anatomically complex cases11,13.

Looking ahead, the field of vascular surgery is expected to undergo further sub-specialization, driven by advances in technology, increasing disease complexity, and evolving healthcare demands. Academic and tertiary care centers are increasingly organizing clinical services around specific pathologies or patient populations. For example, dedicated limb-salvage clinics for patients with chronic limb threatening ischemia, particularly in the context of diabetes—are now recommended by the Global Vascular Guidelines as part of a multidisciplinary strategy to improve limb preservation rates and reduce amputation risk14. In parallel, specialized fellowships and focused training pathways in areas such as complex aortic pathology, advanced peripheral arterial disease, venous disorders, and hemodialysis vascular access are emerging in both North America and parts of Europe15. These trends reflect a broader shift toward precision care and technical specialization.

At the same time, the role of classic open vascular surgery is becoming more concentrated within the high-volume centers. In the United States, for instance, vascular surgery trainees now perform a limited number of open abdominal aortic aneurysm (AAA) repairs, typically between five to ten over the course of their residency, a consequence of the increasing preference for endovascular aneurysm repair (EVAR)16. Nevertheless, data from major academic hospitals indicate that approximately one-third of AAA cases are still managed with open repair, particularly in anatomically complex or younger patients, with some centers reporting 20 to 30 open AAA procedures annually17. As leading experts have emphasized, “open aortic surgery is still necessary in a large number of patients,” underscoring the importance of preserving open surgical skills18. In Greece, as in many other countries, it is anticipated that complex open procedures will be increasingly centralized in specialized referral centers, while interventional and endovascular subspecialties continue to expand and evolve. The future direction of vascular surgery is anticipated to follow two main trends: a steady advancement of minimally invasive, image-assisted procedures, and the continued necessity for open surgical capabilities in particular cases and specialized institutions, according to both worldwide guidelines and the specific requirements of regional healthcare systems.

USE OF MODERN TECHNOLOGIES IN VASCULAR SURGERY

At the beginning of the 20th century, Carrel and Leriche developed the technique of vascular anastomoses, marking the birth of vascular surgery as a distinct specialty. The next revolutionary shift came in the 1990s with the development of endovascular interventions, while today, numerous new techniques complement and improve the field of vascular surgery. Below, we will analyze the main technologies used today, such as hybrid operating rooms, intraoperative angiography (C-Arm), 3D fusion imaging, artificial intelligence, robotic surgery and the application of regenerative medicine in vascular surgery.19

A) Hybrid Operating Rooms

In the past two decades, there has been a significant shift from open surgeries to percutaneous interventions. However, neither the classic operating room nor the conventional angiography suite alone, allow the simultaneous performance of both approaches. Hybrid operating rooms offer a solution by combining a standard operating theater with a fixed, high-end angiography system, enabling the integration of open and endovascular techniques simultaneously, in a sterile environment. This approach reduces overall operative time, the need for follow-up procedures, and the risk of infection. Nevertheless, establishing a hybrid OR requires significant financial investment and appropriately trained surgeons to make optimal use of this technology.

B) Intraoperative Angiography

Modern angiography systems (C-Arm) provide high-definition fluoroscopic guidance in real-time during endovascular procedures, allowing precise placement of stents, catheters, and other devices while reducing complications. In a study of 155 procedures, it was found that in 27 or 17% of cases, complications were detected that could be corrected. These included technical errors in suturing, platelet and atherosclerotic debris accumulation, or unrecognized lesions in the runoff. These findings justify the routine use of intraoperative angiography as a complementary technique in vascular surgery.20

C) 3D Fusion Imaging

3D Fusion Imaging technology allows the integration of preoperative imaging data (CT, MRI) with intraoperative imaging, providing the surgeon with a “navigation map” of the patient’s vascular anatomy. Initially, a 3D model is created from the preoperative imaging (usually a CT scan). This model is then used to plan the surgery, placing specific markers and storing C-arm angles for intraoperative guidance. During the procedure, a cone-beam CT is performed, and the 3D model is aligned with the patient’s anatomy on the table, for real-time navigation. Fusion imaging has been shown in various studies to reduce radiation dose, contrast usage, and procedure time. In the future, fusion models may account for vessel deformation caused by rigid wires and devices, and user-dependent steps may become more automated. In its current form, fusion imaging has already proven to be an essential component in the planning and success of complex endovascular interventions.21

D) Artificial Intelligence in Vascular Surgery

Artificial intelligence (AI) is emerging as a transformative tool in vascular surgery, offering the ability to analyze vast amounts of clinical and imaging data, recognize patterns, and predict outcomes in ways that surpass human capabilities. AI technologies, including machine learning, natural language processing, artificial neural networks, and computer vision, are being explored to assist vascular surgeons in diagnostic imaging interpretation, risk stratification, perioperative management, and outcome prediction. By integrating AI into clinical workflows, vascular surgeons can reduce cognitive load, optimize decision-making, and improve patient-centered care. Although most AI applications in vascular surgery remain in the translational research phase, early studies demonstrate their potential in enhancing non-invasive diagnostics, such as the detection of peripheral arterial disease, and providing real-time support during complex procedures. As the field evolves, addressing technical challenges, data quality, algorithm bias, and ethical considerations will be critical to ensure safe and effective AI integration into vascular practice.21

E) Robotic Vascular Surgery

With the assistance of AI, robotic surgery represents a highly promising new trend, both for vascular and other surgical procedures. It allows the precise manipulation of micro-instruments with sub-millimeter accuracy, reduces radiation exposure for the surgeon, provides enhanced visualization through 3D, high-resolution images of the operative field, and improves ergonomics by enabling the surgeon to operate from a comfortable seated position. However, the absence of haptic feedback may lead to longer operative times, extended learning curves, and an increased risk of surgical errors. Furthermore, robotic systems can apply forces that exceed tissue tolerances, potentially creating a hazardous environment in the absence of haptic feedback.22

F) Regenerative Medicine and Tissue Engineering

Perhaps the most innovative and promising trend in vascular surgery is the application of regenerative medicine and tissue engineering. Research in this field focuses on finding ways to repair or replace damaged blood vessels using the patient’s own cells. This may involve creating new vessels in the laboratory or stimulating the body’s natural regenerative mechanisms to rebuild tissue on its own. Although these techniques are still in their early stages of development, they offer exciting prospects for creating more durable and biocompatible grafts, overcoming the limitations of synthetic materials.23

In conclusion, recent years have seen the emergence of numerous promising new technologies that offer fresh perspectives for surgery as we know it. These technologies enable greater precision, shorter operative times, fewer complications, and a more personalized approach to medicine — whether through tissue regeneration using the patient’s own body or via precise micro-adjustments tailored to each patient’s specific needs. However, all these advancements come at a cost, both in terms of financial investment and the need for specialized surgical training. In our country, unfortunately, the public sector often lacks the resources to acquire such advanced technologies, while in the private sector; access is frequently limited to patients of higher socioeconomic status, creating disparities in healthcare provision.

PERSPECTIVES OF A VASCULAR SURGEON IN GREECE

Vascular surgery, a highly specialized and demanding field, requires extensive training, technical expertise, and the ability to manage complex and often life-threatening conditions. Despite these requirements, remuneration for vascular surgeons in Greece remains disproportionately low. Specialists employed in public hospitals typically earn between €1,200 and €1,800 per month, a figure that fails to correspond with the responsibilities and intensity of their clinical duties. In stark contrast, vascular surgeons in other European countries, such as the United Kingdom and Germany, earn significantly higher salaries—averaging approximately £99,700 (€116,000) annually in the UK and exceeding €7,300 per month in Germany. This pronounced wage disparity contributes to growing professional dissatisfaction and is a key factor behind the emigration of Greek medical professionals seeking more favorable working conditions abroad. Ultimately, such economic imbalances not only devalue the profession but also pose a serious threat to the long-term viability and quality of vascular surgical care within the Greek healthcare system.

Despite the current economic limitations, vascular surgeons in Greece possess considerable potential to contribute meaningfully to both national and international healthcare. Greek medical education is rigorous, and surgical training—particularly in vascular surgery—is known for its high standards and emphasis on clinical excellence. Furthermore, Greek surgeons often demonstrate exceptional adaptability and skill, having gained experience in resource-constrained settings that demand efficiency and innovation. With access to improved infrastructure, research opportunities, and financial support, vascular surgeons in Greece could play a pivotal role in advancing minimally invasive techniques, developing public health strategies for vascular disease prevention, and participating more actively in European collaborative studies. Investing in this specialty not only strengthens the healthcare system but also helps retain talented professionals who are currently compelled to seek better prospects abroad.24-27

CONCLUSION

Vascular surgery stands at the crossroads of tradition and innovation—rooted in the legacy of open procedures and rapidly evolving through minimally invasive technologies and subspecialized approaches. As demonstrated in this review, the field continues to transform in response to emerging challenges, technological progress, and shifting patient demographics. While disparities in training structures, workforce distribution, and compensation—particularly in Greece—pose substantial obstacles, they also illuminate opportunities for reform and advancement. Greek vascular surgeons, despite facing systemic limitations, are uniquely positioned to contribute to the global vascular community through their adaptability, strong clinical foundation, and potential for innovation. Addressing structural weaknesses in training, remuneration, and infrastructure will not only enhance local care delivery but also help to retain medical talent and align Greek vascular surgery with international standards. Ultimately, the future of the specialty relies on a balance between embracing technological breakthroughs and safeguarding the fundamental principles of surgical excellence, access, and equity.

REFERENCES

1. Sidawy AN, Perler BA, Rutherford RB, et al. Vascular surgery training in the United States: A half-century of evolution.
2. Alpagut U, Ricco JB, Setacci C, et al. Education in vascular surgery: Critical issues around the globe—training and qualification in vascular surgery in Europe.
3. Christiansen J, Jakobsen J, Madsen MM, et al. A cross-sectional national study of burnout and psychosocial work environment in vascular surgery in Denmark.
4. Hersey AE, Osborne NH, Lin PH, et al. Vascular surgeon wellness and burnout: A report from the Society for Vascular Surgery Wellness Task Force.
5. Smeds MR, Chang TT, Blair LK, et al. Physical discomfort, professional satisfaction, and burnout in vascular surgeons.
6. Hellenic Statistical Authority. Available from: https://www.statistics.gr/el/home
7. Berufsverband der Deutschen Chirurgie e.V. Available from: https://www.bdc.de
8. The American Board of Surgery. Available from: https://www.absurgery.org/
9. Société de Chirurgie Vasculaire et Endovasculaire de Langue Française. Available from: https://www.vasculaire.com/
10. Kiernan A, Boland F, Harkin DW, et al. Vascular Surgery Workforce: Evaluation and Estimation of Future Demand in the United Kingdom. Ann Vasc Surg. 2022; PMID: 36126835.
11. Suckow BD, Goodney PP, Columbo JA, et al. National trends in open surgical, endovascular, and branched-fenestrated endovascular aortic aneurysm repair in Medicare patients. J Vasc Surg. 2018;67(6):1690-1697.e1. Jayroe H, Weaver L, Velazquez G, et al. Vascular Surgery Training Positions and Applicant 10-Year Trends with Consideration for Further Expansion. Ann Vasc Surg. 2023;95:291-296.
12. ResearchGate. Vascular Surgery in Greece in the Wake of Financial Crisis. Available from: https://www.researchgate.net/publication/309333101
13. Nickinson ATO, Dimitrova J, Houghton JSM, et al. Does the Introduction of a Vascular Limb Salvage Service Improve One Year Amputation Outcomes for Patients with Chronic Limb-Threatening Ischaemia? Eur J Vasc Endovasc Surg. 2021;61(4):612-619.
14. Lok CE, Yuo T, Lee T, et al. Hemodialysis Vascular Access: Core Curriculum 2025. Am J Kidney Dis. 2025;85(2):236-252.
15. Smith ME, Andraska EA, Sutzko DC, et al. The decline of open abdominal aortic aneurysm surgery among individual training programs and vascular surgery trainees. J Vasc Surg. 2020;71(4):1371-1377.
16. Wanhainen A, Van Herzeele I, Bastos Goncalves F, et al. Editor’s Choice – European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms. Eur J Vasc Endovasc Surg. 2024;67(2):192-331.
17. Cleveland Clinic. Analysis Shows Dramatic Declines in Open Vascular Surgery Training in U.S. Available from: https://consultqd.clevelandclinic.org/analysis-shows-dramatic-declines-in-open-vascular-surgery-training-in-u-s
18. Carrel A. Les anastomoses vasculaires et leur technique opératoire. Surgery (Experimental). 1904.
19. Dardik II, Ibrahim IM, Sprayregen S, et al. Routine intraoperative angiography: An essential adjunct in vascular surgery. Arch Surg. 1975;110(2):184-190.
20. Jones DW, Stangenberg L, Swerdlow NJ, et al. Image fusion and 3-dimensional roadmapping in endovascular surgery. Ann Vasc Surg. 2018;52:302-311.
21. Antoniou GA, Riga CV, Mayer EK, et al. Clinical applications of robotic technology in vascular and endovascular surgery. J Vasc Surg. 2011;53(2):493-499.
22. Evans CE, Iruela-Arispe ML, Zhao YY, et al. Mechanisms of endothelial regeneration and vascular repair and their application to regenerative medicine. Am J Pathol. 2021;191(1):52-65.
23. Organization for Economic Co-operation and Development (OECD). Health statistics 2024: Physicians’ remuneration by country. (https://stats.oecd.org/index.aspx?DataSetCode=HEALTH_STAT)
24. World Health Organization. Global health workforce statistics. (https://www.who.int/data/gho/data/themes/topics/health-workforce)
25. Pavlopoulos V, Polyzos N, et al. Medical brain drain in Greece: Causes and impacts. Health Policy. 2020;124(10):1103-1110.
26. European Society for Vascular Surgery. Workforce and remuneration of vascular surgeons across Europe. ( https://www.esvs.org/news-events/publications/)