Expanding the Toolbox for Complex Aorta and Limb Salvage

Complex vascular disease is becoming more prevalent and more complicated. Patients are living longer with diabetes, hypertension, and chronic kidney disease, conditions that accelerate aortic degeneration and peripheral arterial disease. At the same time, advances in imaging, device technology, and minimally invasive techniques have expanded what is technically possible.

The result is a field that demands increasingly nuanced decision-making, particularly for patients with complex aortic aneurysms or chronic limb-threatening ischemia (CLTI), with success in this environment depending on individualized strategy, multidisciplinary coordination, and thoughtful integration of emerging technologies.

Ross Milner, MD, Louis Block Professor of Surgery and chief of the section of Vascular Surgery and Endovascular Therapy at University of Chicago Medicine, explains that the vascular program at UChicago Medicine is built to manage the most challenging aortic cases—patients who are often referred after being deemed too high-risk or too anatomically complex for standard repair.

“Any aortic repair that involves branches of the aorta, to us, is a complex repair,” Milner explained. “So whether it's in the aortic arch, in the chest, in the abdomen, anything that becomes a little bit more than just a repair below the arteries to the kidneys, gets to be complex and requires a team approach.I think that's something that we do very well here with the different specialties that are involved with taking care of those patients.”

Determining whether to pursue open surgery, endovascular intervention, or a hybrid approach requires careful analysis of anatomy, comorbidities, and long-term durability, he says. While endovascular techniques continue to evolve, Milner emphasizes that open repair remains essential in select patients, particularly younger individuals or those with anatomy less suited to stent-based solutions.

Advanced imaging plays a central role in that decision-making process. Milner notes that high-resolution CT reconstruction and three-dimensional planning allow surgeons to map branch vessels, landing zones, and access challenges with increasing precision. He also highlights the growing role of artificial intelligence in postoperative surveillance. AI-driven platforms can help monitor imaging over time, detect subtle changes, and standardize follow-up—tools he believes will improve long-term outcomes and reduce missed complications.

Among these advancements, the recent displays of the Heartflow PCI Navigator have roused substantial excitement. The device, still very much in its pre-clinical investigative phase, will examine CT scan data and leverage AI to generate 3D maps of the patient’s vascular system, allowing clinicians to properly plan optimal stent placement before entering the catheterization lab.

Beyond the aorta, Milner points to chronic limb-threatening ischemia as an area requiring earlier recognition and intervention. Many patients present late in the disease course, when tissue loss and infection increase the risk of amputation. He stresses that limb preservation depends on coordinated care among vascular surgeons, podiatrists, wound specialists, and interventionalists. Early referral, aggressive revascularization when appropriate, and structured follow-up are critical components of preventing limb loss.

Milner also underscores the importance of tailoring therapy rather than defaulting to a single technique. Some patients benefit most from minimally invasive revascularization, while others require open bypass for durable blood flow restoration. The key, he says, is maintaining the full spectrum of expertise so that treatment decisions are driven by patient-specific factors rather than procedural preference.

“The good part for a place like ours is we have many specialists that can take care of peripheral vascular disease and chronic limb threatening ischemia, so we can offer the full spectrum. We do open surgery, we do endovascular approaches, we do hybrid approaches, we do them all, and the decision gets made as we look at the patient's anatomy and look at their overall risk and say, what do we think is best for this given patient?” Milner explained. “I think what's important is to be at a place where all these options are available and we can make the best decision for a patient based on what they need, and not just what an individual provider can do.”

Looking ahead, Milner believes the field will continue to shift toward greater integration of digital planning tools, cloud-based imaging review, and predictive analytics. But even as technology advances, he maintains that outcomes ultimately depend on experience, collaboration, and disciplined clinical judgment.

As vascular disease grows more complex, Milner argues that comprehensive programs—capable of combining innovation with surgical depth—will be best positioned to deliver durable results for high-risk patients.

References

Heartflow. New Heartflow PCI Navigator to Equip Interventional Cardiologists with Pre-procedural Insights to Enable PCI Planning. October 22, 2025. Accessed February 12, 2026. https://ir.heartflow.com/news-releases/news-release-details/new-heartflow-pci-navigator-equip-interventional-cardiologists