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 2023 Charing Cross (CX) International Symposium (25–27 April, London, UK) heard.

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

Black 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 decisionmaking [involved] in order to get the right outcomes for our patients,” she said. “We need to change

Multidisciplinary CX faculty address key issues in the pelvic venous disease space

The deep venous consensus update session at CX 2023 covered a range of key topics in the field, including issues associated with pelvic venous lesions.

THE SESSION OPENED WITH A series of presentations on the pelvic veins, starting with one from Kathleen Gibson (Lake Washington Vascular, Bellevue, USA) 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 that perception.”

Murphy had outlined several ways she sees of helping to curb the problem, building on a talk Manj Gohel (Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK) 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 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 topic of imaging, however, she did note that duplex ultrasound, crosssectional 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. overall.” Similarly, for interventional radiology, the situation is not any better, she reasoned. “Cardiology has no required training. So, what do we do?”

Subsequently, Aleksandra Jaworucka-Kaczorowska (Jaworuccy Center for Surgery and Dentistry, 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 ‘bottom-up’ 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 University Hospitals NHS Foundation Trust, Cambridge, UK) 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.

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 examples 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.”

De Maeseneer receives CX award for dedication to specialist venous care

Marianne De Maeseneer (Erasmus Medical Centre, Rotterdam, The Netherlands) was at the podium to dispense tips for success and longevity as a venous specialist during the superficial and lymphatic consensus update at CX 2023. For Manj Gohel (Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK), no one is better placed to deliver such advice than De Maeseneer, he told symposium attendees.

DE MAESENEER WAS GIVING a talk during the superficial venous and lymphatic session, and Gohel, as co-moderator, was welcoming her to the podium. She kicked off her message by recasting the title as ‘How to be a good and happy venous specialist.’ She shortlisted the keys as curiosity, exchange of ideas, commitment to clinical practice, research and scientific societies, work-life balance and passion. “All these elements were important in my career,” De Maeseneer said. “Passion about the patients, passion about the team you are working with, about research, about education— this is all very important to become and stay a happy and good working venous surgeon, and hopefully long-living venous specialist,” she told CX 2023. At the close of her talk, session comoderator Stephen Black (Guy’s and St Thomas’ Hospital, London, UK) invited De Maeseneer to remain at the podium to receive the CX Lifetime Achievement Award. Presented by Armando Mansilha (University of Porto, Porto, Portugal), she becomes just the second-ever recipient.

“I do not think anyone has put more into defining how we treat our specialty,” said Black. “If any of you can emulate a career in veins, and put veins on the map, Marianne is a great role model to follow.”