Deep venous consensus: Multidisciplinary faculty address key issues in the pelvic venous disease space

Wednesday’s deep venous consensus update covered a range of key topics in the field, including issues associated with pelvic venous lesions. Anchor Erin Murphy (Charlotte, United States) was joined by moderators Armando Mansilha (Porto, Portugal) and Manj Gohel (Cambridge, United Kingdom) to oversee various presentations and edited cases over the course of the afternoon.

THE SESSION OPENED WITH A series of presentations on the pelvic veins, starting with one from Kathleen Gibson (Bellevue, United States) on optimal work-up before intervention for patients with pelvic venous reflux. “This is going to be one of these talks that is full of my opinions and not data,” she said in opening, explaining that this is an area in which there is, as yet, no consensus. Among Gibson’s conclusions was the message that patient history and presentation are important in patients with pelvic venous reflux, urging audience members to “treat the patient, not the imaging”. On the topic of imaging, however, she did note that duplex ultrasound, cross-sectional imaging and venography/intravascular ultrasound “all have important diagnostic roles” and that confirmatory imaging is “very important” to make a definitive diagnosis prior to treatment.

Subsequently, Aleksandra JaworuckaKaczorowska (Gorzow Wielkopolski, Poland) outlined three edited cases on ‘bottom-up’ treatment for pelvic origin varicose veins. She explained that, in her experience, ‘top-down’ treatment does not give good results and that very often multiple embolisation sessions are required. The results of ‘bottomup’ treatment, on the other hand, she has found to be good. This is also a less invasive treatment, she pointed out, adding that it can be repeated if required and is cost-effective.

Moderator Manj Gohel (Cambridge, United Kingdom) noted that the presenter was able to offer a “unique perspective” on this topic due to the fact she is a trained gynaecologist, and, in the discussion following her presentation, Jaworucka-Kaczorowska shared some insights from her practice with an audience of vascular surgeons.

Later in the session, Karen Breen (London, United Kingdom), a consultant haematologist, spoke on the implications of pelvic venous and iliac venous interventions of future pregnancies. She advised delegates to discuss acceptable forms of contraception with these patients and highlighted the importance of pre-conception counselling. Breen also underscored the significance of a multidisciplinary team approach “where practical” and stressed that “more data on outcomes are needed”.

Gibson presented another edited case, focusing on the

Venous, we have a perception problem

Venous disease care has a problem with optics in the context of growth in the number of venous procedures and the spectre of inappropriate care, the CX superficial venous and lymphatic consensus update session heard yesterday morning.

THE CONVERSATION THREAD EMERGED in a question from co-moderator Stephen Black (London, United Kingdom), posed to presenter Erin Murphy (Charlotte, United States), 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 (Cambridge, United Kingdom) 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 currently involves optimum technique for pelvic venous embolisation for pelvic congestion. 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.” Similarly, for interventional radiology, the situation is not any better, she reasoned. “Cardiology has no required training. So, what we do?”

Another topic in the spotlight yesterday afternoon was venous stenting, with faculty including Gerard O’Sullivan (Galway, Ireland), Houman Jalaie (Aachen, Germany) and Marie Van Rijn (Nijmegen, Netherlands), as well as anchor Murphy, speaking on topics including strategies for avoiding venous stent migration and trends and disparities in US venous investigational device exemption trials.

There was also an edited case in this part of the programme on endophlebectomy to optimise inflow for iliac venous stenting from Steven Abramowitz (Washington, United States) and another from Stephen Black (London, United Kingdom) on reintervention for a chronically occluded venous stent.

The answer might be dedicated providers who undertake training and fellowship requirements specific to venous disease, as well as specific board certification, and accreditation. “This is in progress,” Murphy pointed out. “This is probably a direction that we need to go.”

In terms of accountability, she queried whether the venous space should be auditing for decisionmaking when people are trained appropriately. “We have seen when we identify practices that are doing things outside the norm,” Murphy explained, drawing attention to example of practices carrying out more ablations per patient compared to the average practitioner treating venous disease, “when we notified the practice of their outside-the-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 disincentivise. But a multimodal effort to address inappropriate care is needed, and, probably, educating providers is our number one thing.”