VENOUS, WE HAVE A PERCEPTION PROBLEM, CX 2023 HEARS

Venous disease care has a problem with optics in the context of growth in the number of venous procedures and the specter of inappropriate care, the CX Symposium (April 25–27) in London heard.

The conversation thread emerged in a question from co-moderator Stephen Black, MD, from Guy’s and St Thomas’ Hospital in London, England, posed to presenter Erin Murphy, MD, from Sanger Heart and Vascular Institute, Atrium Health, in Charlotte, North Carolina, who had just presented possible solutions that can be targeted at not only discouraging inappropriate venous care but also encouraging appropriately administered procedures.

Having trained and carved out a career as a venous specialist, said Black, if he were to suddenly decide “to now go and do a coronary angiogram and stent, I would get absolutely obliterated.” So, he asked Murphy: “Why is it that it is so easy for people who have never trained in veins just to crack on and treat veins without any consequences?”

Murphy pointed to a problem with misperception—“that this is an easy patient subset to treat, and I think those of us who are in this room treating these patients know that there is actually very complex decision-making [involved] in order to get the right outcomes for our patients,” she said. “We need to change that perception.” Murphy had outlined several ways she sees of helping to curb the problem, building on a talk Manj Gohel, MD, from Cambridge University Hospitals in Cambridge, England, gave last year.

They included defining appropriate care through research initiatives, consensus statements and guideline data; educating and disseminating such data; holding practices accountable for decisions to carry out inappropriate care; and establishing correct financial incentives. The biggest of these challenges involves educating a sprawling array of providers who treat venous disease patients, Murphy said. Are the right doctors treating the venous disease population?

Vascular surgeons, for instance, “have no requirement in their board certification to be treating venous patients,” Murphy said, asking whether they are well-enough trained in the venous area. “Coming out of training, they have done about 40 venous cases overall.” For interventional radiology, the situation is no better, she reasoned.

The answer might be dedicated providers who undertake training and fellowship requirements specific to venous disease, as well as specific board certification, and accreditation. In terms of accountability, she queried whether the venous space should be auditing for decision-making when people are trained appropriately.

“We have seen when we identify practices that are doing things outside the norm,” Murphy explained, drawing attention to an example of those carrying out more ablations per patient compared to the average practitioner treating venous disease, “when we notified the practice of their outsidethe-box numbers, they actually self-corrected to an extent.” The implication here is that they had been educated, she added.

“Underdiagnosis and undertreatment probably affect more patients than overtreatment, particularly over time,” Murphy said. “So, we do not want to disincentivize. But a multimodal effort to address inappropriate care is needed, and, probably, educating providers is our number one thing.”—Bryan Kay

By Jamie Bell

LITHOTRIPSY MAY HOLD THE KEY TO ENABLING more carotid artery disease patients who require calcification treatment to undergo stent placement via a transcarotid artery revascularisation (TCAR) procedure, as per single-center experiences presented at the recent Society for Clinical Vascular Surgery (SCVS) Annual Symposium in Miami (March 25–29) by Kathryn DiLosa, MD, a University of California (UC) Davis, Sacramento, vascular surgery resident, alongside principal investigator Misty Humphries, MD, interim chief of the division of vascular surgery at UC Davis.

In cases of circumferential or eccentric calcification, TCAR is precluded and carotid endarterectomy (CEA) often becomes the preferred approach—however, in patients considered “high risk” due to their anatomy or prior surgeries, for example, “another alternative exists,” the speaker averred.

Detailing the use of intravascular lithotripsy (IVL) prior to a TCAR procedure, DiLosa noted that predilation angioplasty may be required to allow passage of a lithotripsy balloon, and the balloon “should be sized to fully oppose the vessel wall, but not extend past the intended coverage area.” She further stated that lithotripsy technologies have been used in the treatment of kidney stones previously, and are now shifting into the endovascular space.

The speaker also reported a 100% rate of technical success with this approach at her institution, across a total of seven patients, with comparable procedural and flow-reversal times to standard TCAR, and no observed complications within 30 days of the procedure.

“However, a larger cohort [of patients] is still needed to confirm safety,” DiLosa said.

Responding to an audience query on how lithotripsy is able to successfully break up calcium without leading to embolization—a concern she admitted to having initially herself—DiLosa added that “all of the available literature has demonstrated that it is able to fracture the calcium, within the wall, without it embolising from the wall.”

Briefly touching on the available literature regarding preTCAR lithotripsy, she stated that case studies—but no significant case series—are available at this point, although she and her colleagues are currently compiling a multi-institutional cohort including more than 50 patients.

“This is definitely for a specific patient population—those who cannot tolerate endarterectomy, but that would need the benefit of calcification,” DiLosa concluded.

Meanwhile, a recent debate between two prominent carotid interventionists—Peter Schneider, MD, professor of vascular and endovascular surgery at University of California San Francisco, and Domenico Valenti, MD, professor of vascular surgery at King’s College London in London, England—at the 2023 CX Symposium (April 25–27) in London revealed that the vascular community is currently divided over the benefits of TCAR, as compared to percutaneous carotid artery stenting (CAS). An audience poll produced showed more attendees concur with Valenti’s closing gambit that “TCAR is not about to send CAS to oblivion,” as 52% voted against the statement that “TCAR is better than percutaneous carotid stenting,,” as argued by Schneider.