Endovascular vs. Open Vascular Surgery: How Surgeons Choose the Right Approach

Why Is There More Than One Way to Fix a Blocked Artery?

Not long ago, the only way to treat a severely narrowed or blocked artery was open surgery. The surgeon made a long incision, exposed the diseased vessel, and either removed the plaque or sewed a bypass graft around the blockage. That approach worked well, but it required significant recovery time and carried notable surgical risks.

Then came endovascular surgery. Instead of a large incision, the surgeon makes a tiny puncture in the groin or arm, threads a thin catheter through the artery, and opens the blockage from the inside using a small balloon or a stent. Recovery is faster, hospital stays are shorter, and patients often go home the next day.

Now, for the first time in history, vascular surgeons have two powerful tools to treat the same problem. The question is no longer “Which method is better?” The question is “Which method is better for this specific patient at this specific time?” The answer depends on a careful assessment of anatomy, patient health, available vein conduit, and the patient’s own goals and preferences.

At Silicon Valley Surgical Associates (SVSA), our vascular surgeons are trained and experienced in both endovascular and open surgical techniques. We do not favor one approach over the other. Instead, we match the procedure to the patient. This article explains how we make that decision, what the evidence shows, and what you can expect from each approach.

What Exactly Is Endovascular Surgery and How Does It Work?

Endovascular surgery refers to any procedure performed inside the blood vessel using catheter-based technology. The surgeon accesses the artery through a small puncture, usually in the common femoral artery in the groin. Through this single puncture, which is typically smaller than a pencil eraser, the surgeon can treat blockages anywhere from the groin down to the foot.

The most common endovascular procedures include:

• Angioplasty: A small balloon is inflated inside the narrowed artery, compressing the plaque against the vessel wall and opening the channel for blood flow.
• Stenting: After angioplasty, a small metal mesh tube (stent) is deployed to keep the artery open. Some stents are coated with medication (drug-eluting stents) to reduce the risk of re-narrowing.
• Atherectomy: A specialized catheter with a cutting or grinding device removes plaque from the artery wall. This is typically reserved for heavily calcified lesions that do not respond well to balloon angioplasty alone.
• Drug-coated balloon: A balloon coated with paclitaxel or another anti-proliferative drug is inflated in the artery, delivering medication directly to the vessel wall to prevent restenosis.

The advantages of endovascular surgery are significant. Recovery is faster. Hospital stays are shorter. Patients often go home the day after the procedure and return to normal activities within one to two weeks.

However, endovascular surgery is not without limitations. The long-term durability of stents and balloons is generally lower than that of a well-constructed open bypass using the patient’s own vein. Patients with extensive, heavily calcified blockages may not be good candidates for endovascular treatment. And some lesions, particularly long occlusions (complete blockages) extending from the groin to the knee, have poor endovascular outcomes.

What Is Open Vascular Surgery and When Is It Preferred?

Open vascular surgery involves making an incision directly over the diseased artery and performing a reconstruction. For lower extremity PAD, the most common open procedure is a bypass graft.

In a femoral-popliteal or femoral-tibial bypass, the surgeon makes an incision in the groin and another incision in the leg below the knee or at the ankle. A conduit (a blood vessel used as a replacement) is sewn above and below the blockage, creating a new route for blood to flow around the diseased segment.

The best conduit by a wide margin is the patient’s own great saphenous vein, the large vein that runs from the ankle to the groin along the inner leg. When the saphenous vein is healthy and of adequate diameter, it provides excellent long-term patency (the rate at which the bypass remains open). When the saphenous vein is unavailable (because it was previously removed for coronary bypass, is too small, or is diseased), surgeons may use a prosthetic graft made of polytetrafluoroethylene (PTFE) or polyester (Dacron). Prosthetic grafts have lower patency rates than vein grafts, particularly for bypasses that cross the knee joint.

The main disadvantages of open surgery are the longer recovery time, larger incisions, and higher rates of wound complications. Surgical site infection is a particular concern for groin incisions. Hospital stays are also longer. The BEST-CLI trial, the largest randomized trial comparing surgery and endovascular therapy for CLTI, reported a median hospital stay of 6 days for the bypass group compared to 3 days for the endovascular group.

What Does the BEST-CLI Trial Tell Us About Choosing Between Surgery and Endovascular Therapy?

The BEST-CLI trial (Best Endovascular vs Best Surgical Therapy for Patients with Chronic Limb-Threatening Ischemia) is the largest and most current randomized clinical trial comparing surgical bypass and endovascular therapy for CLTI. It enrolled 1,830 patients with CLTI across 150 sites in the United States, Canada, Finland, Italy, and New Zealand.

Patients were divided into two cohorts. Cohort 1 (1,434 patients) had a single segment of great saphenous vein suitable for use as a bypass conduit. Cohort 2 (396 patients) did not have a suitable saphenous vein and required an alternative conduit if assigned to surgery.

The results were striking. In Cohort 1 (patients with a suitable saphenous vein), the surgery-first strategy had a 32% lower risk of the composite outcome of major adverse limb events or death compared to the endovascular-first strategy. Secondary outcomes including all-cause mortality, amputation, perioperative death, and cardiovascular events such as myocardial infarction and stroke were similar between the two groups.

In Cohort 2 (patients without a suitable saphenous vein), there was no significant difference in the primary endpoint between surgical bypass and endovascular therapy. This finding reinforces that when a patient lacks good vein conduit, the choice between surgery and endovascular treatment requires careful, shared decision-making.

Nevertheless, BEST-CLI provides the strongest evidence to date. For patients with a suitable saphenous vein and CLTI, surgical bypass should be strongly considered as the initial strategy. For patients without a suitable vein, the evidence does not favor one approach over the other, and the decision must be individualized.

The table below summarizes the key factors that guide the choice between endovascular and open surgical revascularization.

What Are Hybrid Procedures and Who Benefits From Them?

Not every patient fits neatly into an “endovascular only” or “open only” category. Many have disease at multiple levels, such as a blockage in the iliac artery (in the pelvis) and another in the superficial femoral artery (in the thigh). For these patients, the best approach may be a hybrid procedure that combines endovascular and open techniques in a single operation.

A common hybrid procedure involves open surgical exposure of the common femoral artery in the groin, followed by endovascular treatment of the iliac or superficial femoral artery through that same exposure. The surgeon removes plaque from the femoral artery (a procedure called femoral endarterectomy) and then passes a balloon or stent into the downstream vessels. This single operation treats both the inflow (iliac) and outflow (femoral) disease without the need for separate procedures or larger incisions.

Hybrid procedures require a dedicated hybrid operating suite equipped with high-quality fluoroscopy (X-ray imaging) and the full range of surgical instruments. At SVSA, we perform hybrid revascularization in an accredited hospital setting with state-of-the-art imaging and a highly experienced team of vascular surgeons, anesthesiologists, and nurses. If you have multilevel disease, your surgeon may recommend a hybrid approach to minimize the number of operations and speed your recovery.

What Is New in Vascular Surgery for No-Option CLTI Patients?

Some patients with CLTI are not candidates for either traditional bypass or endovascular revascularization. Their arteries may be too heavily calcified, too small (especially below the ankle), or completely occluded with no suitable target vessel for a bypass. These patients, sometimes called “no-option” CLTI patients, historically faced amputation rates as high as 67% at one year.

A transformative new technology called transcatheter arterialization of the deep veins (TADV) offers hope. Instead of trying to restore flow through the blocked arteries, TADV creates a new pathway by connecting a leg artery to a deep vein. The vein carries oxygenated blood down to the foot in the reverse direction, bypassing the blocked arteries entirely.

TADV is not appropriate for all CLTI patients, but for those with no conventional revascularization options, it offers a chance at limb salvage that did not exist a few years ago. If you have been told that nothing more can be done for your leg, ask your vascular surgeon about TADV.

How Do Surgeons at SVSA Choose the Right Approach for You?

At SVSA, the decision between endovascular and open surgery is never made in a vacuum. It is a collaborative process involving the patient, the vascular surgeon, and often other specialists such as cardiologists, nephrologists, and wound care experts.

The process typically follows these steps:

• Diagnostic imaging: You will undergo a duplex ultrasound and either a CT angiogram or an invasive angiogram to map your arteries in detail. This imaging shows where the blockages are, how long and how severe they are, and whether your saphenous vein is healthy enough to use as a bypass conduit.
• Medical optimization: Before any procedure, your medical conditions will be optimized. This includes blood pressure control, blood sugar management if you have diabetes, smoking cessation (if you smoke), and sometimes cardiology evaluation to assess your risk of heart attack or stroke during surgery.
• Risk-benefit discussion: Your surgeon will explain the risks and benefits of each approach, specifically for your anatomy and your overall health. You will learn about the expected recovery time, the long-term patency rates, and the need for follow-up imaging or medications.
• Shared decision-making: You will have the opportunity to ask questions and express your preferences. Some patients prioritize a faster recovery and are willing to accept a higher chance of needing a repeat procedure in the future. Others prioritize long-term durability and are willing to accept a longer initial recovery.
• Procedure and follow-up: Once you and your surgeon agree on the best approach, the procedure will be scheduled. Afterward, you will be entered into a surveillance program that includes regular duplex ultrasound to monitor the treated vessel or graft for signs of restenosis or blockage.

Minimally invasive surgery has become the new standard of care for many vascular conditions, but “minimally invasive” does not always mean “best.” For some patients, open surgery remains the superior option. The same is true for new technologies in vascular surgery, such as drug-coated balloons, atherectomy devices, and transvenous bypass systems. These tools expand the options available, but they do not replace the fundamental decision-making process that puts the patient first.

Patient safety in surgery and endovascular procedures is our highest priority. We adhere to rigorous protocols for preoperative antibiotic prophylaxis, venous thromboembolism prevention, and surgical site infection reduction. Every patient receives a comprehensive preoperative evaluation, including assessment of abdominal aortic aneurysm risk when indicated, to ensure that no hidden danger is overlooked.

Medical Disclaimer

This information is for educational purposes only and does not replace professional medical advice. Always consult your physician or a vascular surgeon for any health concerns or before starting any treatment.

Frequently Asked Questions About Endovascular vs. Open Vascular Surgery

Author and Review Information

Author: Charles D. Goff, MD, FACS

Medical Reviewer: Jacek J. Paszkowiak, MD, FACS

Last reviewed: March 17, 2026