Vein Magazine Volume I Issue 2 by OutClick

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Trial Attorney Kenneth McKenna on Limiting Liability Exposure ACP Becomes Member of AMA Specialty and Service Society Incorporating Phlebology Into a Dermatology Practice Notes From ACP Conference in Tucson

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Advanced Practical Phlebology Symposium

Learn. Network. Grow. American College of Phlebology 22nd Annual Congress

September 12 â&#x20AC;&#x201C; September 13, 2008 Greensboro, North Carolina

November 6-9, 2008 Marco Island Marriott Resort & Spa Marco Island, Florida

This intensive two-day workshop provides advanced practical experience in the diagnosis and treatment of superficial venous disease. Participants will join national experts for advanced learning through both didactic lectures and workshops in the clinical evaluation of phlebology patients.

The ACP Annual Congress is a premier educational forum for the diagnosis, treatment, and management of venous disease. Join leaders in the field of phlebology for abstract sessions, interactive sessions, workshops, live patient demonstrations, and special interest sections for ultrasonography and nursing.

Visit www.phlebology.org/meetings for more information.

Visit www.acpcongress.org for more information.

Research Grants & Awards Available The American College of Phlebology is offering over $150,000 in phlebology research grants and awards. Grants are open to individuals in all levels of phlebology including graduate students, junior faculty, clinicians, and more. Please visit www.phlebology.org/research for more information.

Apply today!

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Publisher’s Note

8 Letter from Dr. Zimmet The American Board of Phlebology

Vein Industry Calendar

Upcoming events

12 The L Factor: Risks and Consequences of Compounded Sclerosing Agents By Kenneth McKenna, Esq.

Incorporating Phlebology Into a Dermatology Practice

By Neil Sadick, M.D., FACPh

20 A New Treatment Paradigm: Venous Stasis Ulcers By Barbara S. Zuniga, M.D. 23

ACP Joins AMA Specialty and Service Society

By Michael P. Krusch, M.D., FACPh

Medical Diary

21st Annual Congress of the ACP By John Mauriello, M.D., FACPh

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VEIN About Town

Highlights from the ACP Annual Congress STAR PASS RESORT, Tucson, AZ

30 Featured Doctor AVC’s Bruce Hoyle, M.D. by David DelVal

VEIN News and New Products

34 Design Corner Medical Co-Op Reinvigorates Age-Old Interior By Susan Belknapp

IVC Holds Clinical Sessions for Vein Surgeons

By David DelVal

Phlebology International

Germany Society of Phlebology By Claudia Schou

Education: Getting Beyond the Basics

Education: Catheter Tips for Beginners

By Steve Elias, M.D., FACS

By Wayne Gradman, M.D.

Vein Industry Resources Spotlight:

BSN Medical Inc. By Dean J. Bender,Vice President R & D

48 Case Study: Sciatic nerve varices By Jose Almeida, M.D., FACS, RVT

On the cover Kenneth J. McKenna, Esq. Photo Tammy Middleton

www . veindire c tory . org

P u b l i s h e r ’s N o t e It is with great pleasure that I welcome you back to VEIN magazine. In this issue our spotlight is on innovative new strategies and technologies in phlebology. Our articles range from education in the industry to vascular medicine internationally. VEIN is pleased to present an exclusive interview with an internationally recognized phlebology expert from Germany, Eberhard Rabe, M.D.. Dr. Rabe gives us a global perspective on vascular medicine; we get a personal look inside the growing field of phlebology practices in Germany as well as all over Europe, which has made significant strides in advancing vascular technology. The European industry is gaining recognition across the world for its outstanding educational systems and efforts in the advancement of phlebology. Education is another aspect of phlebology that VEIN is beginning to cover with this issue. In fact, one of this edition’s articles focuses solely on phlebology education today and where the field hopes to be in the future. VEIN is actively involved in the quest to further progress, education and technology for the industry. VEIN hopes to be a tool for you to learn about some of the latest research; as the sphere of vascular medical procedures further flourishes, we will help guide you and your practice into the new era of phlebology. Aimed at giving you useful information, VEIN’s cover story this quarter delves into an important and often misunderstood area. Attorney Kenneth J. McKenna discusses physician use of compounded sclerosing agents. He delves into compounding pharmacies and the legal challenges related to the use of compounded sclerosing agents. We hope to provide you with the highest quality of information and writing possible. Whether you are a physician, patient or simply someone interested in medicine, I personally feel our cover story will be of great interest for you all. The insights and in-depth analysis of these issues will serve as an important platform for making decisions about treatment.

Claudia Schou Editor-in-Chief

Publisher Ali Jahangiri, Esq. Medical Director Steven E. Zimmet, M.D., RVT, FACPh Copy Editor Kristinha Anding CONTRIBUTING WRITERS Jose Almeida, M.D., FACS, RVT Susan Belknapp Dean J. Bender David DelVal Steve Elias, M.D., FACS Wayne Gradman, M.D. Bruce Hoyle, M.D. Michael Krusch, M.D., FACPh Kenneth J. McKenna, Esq. John Morriello, M.D. Neil Sadick, M.D., FACPh PRODUCTION Creative Director Frank Chlarson Photography Tammy Middleton ADVERTISING Account Manager David Sveen

Our first issue of VEIN, launched in November at the American College of Phlebology’s 21st Annual Congress, was a big hit. I would like to personally thank all the supporters, readers and physicians promoting VEIN magazine, veindirectory.org, and our goal of encouraging awareness and advancement in our industry. We look forward to hearing from you and hope to be your leading source for phlebology information in print with VEIN and online via veindirectory.org.

Account Manager Kristin Nicoletti Administration Bettina Kina

VEIN

96 Discovery Irvine, CA 92618 www.veindirectory.org 888.334.8346 Vein Magazine is a publication of veindirectory.org

Best regards, Ali Jahangiri

Printed in the U.S.A. Copyright Outclick Media. All rights reserved. VEIN Magazine is printed 4 times per year by Outclick Media. Address all subscription correspondence to VEIN Magazine, 96 Discovery, Irvine, CA 92618. Please allow at least six weeks for change of address. Include your old address as well as new, and if possible, enclose an address label from your recent issue.

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Letter from Our Medical Director

American Board of Phlebology The

It is a pleasure to announce a historic milestone in phlebology: the creation of an independent specialty board. This development will contribute significantly to the recognition and acceptance of phlebology as well as serve to improve standards of patient care. It is an important affirmation for those who have chosen to contribute to and work in the field of venous disease. The American Board of Phlebology (ABPh), an independent nonprofit organization, is organized under the laws of the state of Illinois for scientific and educational purposes. No part of its net earnings shall be applied to the benefit of any director, officer or other individual. The Board is organized to: 1) Improve the standards of medical practitioners and the quality of patient care related to the treatment of venous disorders and all aspects of venous disease 2) Serve the public and the medical profession by establishing initial and continuing qualifications for certification and maintenance of certification as physician specialists in the practice of phlebology 3) Examine physician candidates for certification and maintenance of certification in the practice of phlebology 4) Establish educational standards for teaching and training programs in phlebology 5) Maintain a registry of individuals who hold certificates issued by the Board It is not the purpose of the Board to define requirements for membership on hospital staffs, to gain special recognition or privileges for its diplomates in the practice of phlebology, or to define the scope of phlebology practice. The Board does not define who may or may not practice phlebology. It is neither a source of censure nor an entity for the resolution of ethical or medical-legal issues. Medical specialty certification in the United States is a voluntary process. While medical licensure sets the minimum competency requirements to diagnose and treat patients, it is not specialty specific. Board certification demonstrates a physician’s commitment and expertise in a particular specialty and/or subspecialty of medical practice.

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The American Board of Phlebology Certification Exam will be delivered via Pearson Vue testing centers, located throughout the United States and internationally, on April 5 and April 7–12, 2008. The exam is open to licensed physicians who meet rigorous prerequisite qualifications in phlebology training or experience and professional standing. Candidates who wish to sit for the examination must: 1) Submit an application form, including required information and fees 2) Fulfill prerequisite minimum standards of phlebology involvement 3) Meet professional standards 4) Verify that they understand and agree to Board policies The Board does not sanction the term “board eligible.” Acceptance for examination, only determined after formal application, acknowledges only that the candidate has successfully fulfilled the requirements and does not certify that he or she is a specialist in phlebology. The Board is made up of of seven directors. For more information on thier backgrounds, please see page 32. You can find the criteria, application and important dates related to the certification exam as well as policies and other information about the certification exam and the Board at www.AmericanBoardofPhlebology.org. The American Board of Phlebology neither administers nor endorses review courses for ACPh examinations. The Board does provide a document about exam content and content weighting, but does not provide guidance to organizations offering review courses. Participation in review courses does not ensure successful completion of the certification exam. CONTACT INFORMATION The American Board of Phlebology 100 Webster St., Ste. 101 Oakland, CA 94607-3724 Tel: 510.834.6500 Fax: 510.832.7300 Web site: www.AmericanBoardofPhlebology.org

Steven E. Zimmet, M.D., RVT, FACPh

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Sixth International Vein Congress® Office-based Venous Surgery

April 17-19, 2008 InterContinental Miami Miami, Florida

Are you serious about your vein practice? The International Vein Congress® is the single most important meeting for today’s vein specialist. IVC offers renowned, comprehensive education for both veterans and newcomers wanting to advance in their chosen area of interest. Come to IVC and take advantage of: • • • • • • •

Live case demonstrations from the Miami Vein Center Coverage of basic and advanced endovenous techniques Sessions on sclerotherapy and light/laser therapy of small veins Sessions on saphenous and nonsaphenous vein issues Sessions on deep vein thrombosis and hypercoagulable states An exhibit hall dedicated to the latest technology and services New! Option to download presentation slides as PDFs for easy note taking during the meeting (Bring along your laptop.)

In addition to an emphasis on vein removal and treatment – including the use of tumescent anesthesia, ultrasound and other advanced technology – the course covers secondary services and additional procedures for which demand continues to grow. Discussion of business aspects, such as marketing and liability, will complement the highlighted clinical applications and teach you how to effectively expand your practice and boost your bottom line.

Course Director Jose I. Almeida, M.D. Course Co-directors Edward G. Mackay, M.D. Nicos Labropoulos, Ph.D. Ronald G. Bush, M.D. Lowell S. Kabnick, M.D.

Calendar

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March 5 – 8, 2008 36th Annual Symposium Society for Clinical Vascular Surgery Caesars Palace Las Vegas, NV For more information, visit www.scvs.vascularweb.org, or contact the Society for Clinical Vascular Surgery at (978) 927-8330 March 15 – 20, 2008 33rd Annual SIR Scientific Meeting Society of Interventional Radiology Washington Convention Center Washington, D.C. For more information, visit www.sirmeeting.org or contact the Society of Interventional Radiology at (703) 691-1805 April 4 – 5, 2008 Ninth International Congress of Phlebology Bologna, Italy For more information, visit www.valet.it April 12 – 15, 2008 30th International Symposium Vascular & Endovascular Consensus Update Charing Cross Imperial College London, United Kingdom For more information, visit www.cxsymposium.com April 17 – 19, 2008 Sixth Annual Meeting International Vein Congress InterContinental Hotel Miami, Fla. For more information, visit www.ivconline.org or contact the Miami Vein Center at (305) 854-1555

May 10 & May 12 – 17, 2008 Board Certification Exam American College of Phlebology For more information about the exam or to find an exam location near you, visit, www.phlebology.org or contact the American College of Phlebology at (510) 834-6500 May 15 – 17, 2008 12th European Vascular Course Amsterdam, The Netherlands For more information, visit www.european-vascular-course.org May 30 – 31, 2008 Annual Meeting for Endovenous Treatments of Varicose Veins in 2008: A Close Up Benelux Society of Phlebology Maastricht, The Netherlands For more information, visit www.phlebologybenelux.org June 26 – 28, 2008 Ninth Annual Meeting European Venous Forum Hotel Fira Palace Barcelona, Spain For more information, visit www.europeanvenousforum.org November 6 – 9, 2008 22nd Annual Congress American College of Phlebology Marriott Resort Golf Club & Spa Marco Island, Fla. For more information, visit www.phlebology.org or contact the American College of Phlebology at (510) 834-6500

The Inter Continental Hotel in Miami soars 34 stories from the heart of the city center with a contemporary flair that’s pure Florida.

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Submissions to the calendar should be e-mailed to the editor at mag@veindirectory.org. Please include the event’s name, date, time, location, admission price, and contact information. Inclusion in the calendar is subject to available space.

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Compounded Sclerosing Agents

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RISKS & FACTOR By: Kenneth J. McKenna, Esq.

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For decades, patients have sought medical treatment for unsightly and sometimes painful varicose and spider veins. One common procedure to treat this type of venous disease is sclerotherapy: the injection of a sterile agent into the affected vein, which, in response, collapses and is reabsorbed. Beginning in the mid-20th century, most physicians in the United States used FDA-approved Sotradecol® (sodium tetradecyl sulfate) manufactured by Elkins-Sinn Inc., as a sclerosant to eradicate such veins. When Elkins-Sinn pulled Sotradecol® from the U.S. market in 2000, physicians began to look elsewhere for sclerosing agents, including domestic and foreign compounding pharmacies. Although Sotradecol® once again received FDA approval in 2004 and returned to the market through a joint venture between Bioniche Pharma Group Ltd. and AngioDynamics Inc., many physicians continue to purchase non-FDA-approved sodium tetradecyl sulfate and polidocanol from compounding pharmacies. However, there can be grave liability risks and legal consequences associated with physician use of compounded sclerosing agents. In concept, compounding pharmacies exist to allow pharmacists to combine, mix or alter ingredients to create unique medications that meet the particular needs of individual patients. According to the FDA, it is “. . . a practice that is under FDA scrutiny – mainly because of instances where compounded drugs have endangered public health.” Much of the criticism directed at compounding pharmacies has focused on the fact that pharmacy compounding has evolved from a patient-specific practice to a global massproduction industry that consciously avoids the scrutiny of government oversight. It is one thing to compound a

of FDA-approved agents for a fundamental reason wholly unrelated to product performance or patient safety. That reason is money. All things being equal, a compounded agent will generally cost less than its FDA-approved equivalent. As a result, a cost-conscious physician may elect to utilize a compounded agent in an effort to reduce overhead and increase his profit margin.

The simple fact that compounded products have not been subjected to FDA testing to determine their safety and effectiveness places those physicians who choose to use these products at significant risk of legal liability in the event of an adverse outcome. A physician utilizing an FDA-approved agent can proceed with the comfort of knowing that the product was manufactured according to pharmaceutical-grade standards and was subject to the FDA’s testing and approval process. To the contrary, a physician utilizing a compounded agent has no such assurances. Because compounding pharmacies are not FDA-regulated, the products they provide are not nearly as consistent or reliable. At worst, compounded products can be contaminated and cause devastating consequences for the patients to whom they are administered. The FDA’s files are replete with reports of compounding nightmares, ranging from patient deaths caused by the use of contaminated compounded solutions during heart surgery to blindness from contaminated products used during cataract surgery. Even compounded products free from contamination can pose serious danger to the consumer. In many cases, the potency or concentration of the drug is inconsistent with product

Photography by Tammy Middleton

CONSEQUENCES medication to account for a patient allergy or to provide a safe dose for a child; it is something altogether different to mass produce and distribute a product such as sodium tetradecyl sulfate to physicians around the country. The simple fact that compounded products have not been subjected to FDA testing to determine their safety and effectiveness places those physicians who choose to use these products at significant risk of legal liability in the event of an adverse outcome. It is important to acknowledge there are certainly legitimate reasons for physicians to utilize compounded agents in their day-to-day practice. For example, a physician may have a genuine clinical preference for a compounded version of an agent versus the commercially available, FDA-approved alternative. However, it must also be acknowledged that many physicians choose to utilize compounded agents in lieu

labeling, leading to inappropriate dosing and sometimes serious adverse events. In several well-publicized cases around the country, patients have been injured or killed by improperly mixed agents with toxic doses many times more potent than their labeling indicated. When a patient experiences an adverse outcome from a medical procedure, there is always a risk the patient will take legal action against the physician or facility that provided the care. In evaluating medical negligence claims, an attorney must identify the medical cause of the injury before going forward with a claim against the health-care-provider. If the medical cause of the injury is a commercially available FDAapproved product, the target of the claim will usually shift to the manufacturer of the product. On the other hand, if the medical cause of the injury is a compounded agent, the compounding pharmacy may not have sufficient insurance in Continued on page 14

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place to cover malpractice How deep are your pockets? claims. If this is the case, then the malpractice claim will fall upon the physician and facility that utilized the compounded agent. The patientâ&#x20AC;&#x2122;s attorney will invariably attempt to determine why the compounded agent was utilized and whether an FDA-approved alternative was available to the health-care-provider. Accordingly, any physician who is utilizing or is considering utilizing a compounded agent should closely consider the following questions: 1) Why did you utilize a non-FDA-approved product when one is available? 2) Where and when was the agent compounded? 3) What steps did you take to ensure that the compounded agent you used was manufactured in an FDA-registered facility? 4) Do you purchase the agent in bulk? If so, how is it stored and what steps do you take to ensure dosage consistency?

6) Have you ever visited the compounding pharmacy? 7) Where does the compounding pharmacy acquire its raw materials? Are they all pharmaceutical grade? 8) Do you use compounded agents to increase profit? After considering the foregoing questions, most reasonable physicians will conclude that they should utilize FDA-approved agents whenever possible or risk exposure to a malpractice claim from a patient injured by a compounded agent. The decision to reduce office expenses in lieu of patient safety will often prove to be devastating to the physician.

When a patient experiences an adverse outcome from a medical procedure, there is always a risk the patient will take legal action against the physician or facility that provided the care. In todayâ&#x20AC;&#x2122;s medical-legal environment, all physicians should strongly consider the potential moral and legal consequences of utilizing compounded agents. At a minimum, a physician committed to the use of compounded agents must be able to medically justify the use of the compounded agent and ensure that the compounding pharmacy complies with all applicable state and FDA regulations.

5) How did you test the compounded agent to ensure that it was safe? Do you test each batch?

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Incorporating

PhlebologyInto a DermatologyPractice By Neil Sadick, M.D., FACPh

Dermatologists are natural experts in the evaluation and management of skin-related problems. It is a natural fit and progression for them to be involved in the management of venous disorders. Almost on a daily basis, they diagnose and manage sequelae and manifestations of both superficial and deep venous incompetence such as stasis dermatitis, stasisrelated pigment dyschromia, venous ulcers and end-stage lipodermatosclerosus.

By Neil Sadick, M.D.

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Considering these facts, it is a natural fit for dermatologists to incorporate phlebology into their practice. However, this does require decision making, the learning and incorporation of new skill sets, the purchase of required capital equipment, the hiring of trained and skilled personnel, and consideration of other issues that will be discussed further in this article.

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In addition, it is well known that several dermatologists have been major thought leaders, pioneers, innovators and educators in phlebology in the United States.These physicians include David Duffy, Mitchel Goldman, Robert Weiss and Steven Zimmet. These individuals have advanced the speciality of phlebology as dermatologists and continue to make active contributions to the development of this field. These following factors should encourage all dermatologists to take an increased interest in incorporating phlebology into their practices. Benefits of Incorporating Phlebology Into a Dermatology Practice There are many benefits of incorporating phlebology into a dermatology practice. Perhaps the most important is the increased satisfaction physicians feel, knowing that they are expanding their medical knowledge and procedural capabilities. The steps nessessary to evolve a sophisticated phlebology venue will be discussed in the next section.

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Adding phlebology to your dermatology practice increases the spectrum of services your practice offers. This translates into adding more patients to your base, which translates into more patients who can potentially utilize other medical and esthetic dermatologic services, such as fillers, toxins and hair transplantation. By increasing patient number and by transferring these patients to other provided services you will ultimately gain increased practice income. A third reason to incorporate phlebology into your dermatology practice is to become one of the few dermatologists who have a sophisticated phlebology practice that goes beyond performing sclerotherapy and handling cosmetic spider veins. By being known for more advanced phlebologic procedure, giving lectures and seminars in this subject to both patients and colleagues, you will gain an increased number of patient referrals. This will continue to augment your practice visibility, prestige and income. Taking the Next Step There are things you can do to incorporate phlebology into your dermatology practice: • Take advanced courses • Read comprehensive textbooks on phlebology • Learn the skill of duplex ultrasound • Hire and train personnel • Set up a phlebology suite • Add equipment to your practice (external lasers, endovenous laser and radiofrequency technology) • Set up a marketing/patient education program • Obtain board certification If a dermatologist wants to advance his skills in phlebology, he needs to take advanced courses on phlebology. Goldman and Weiss have excellent course manuals on learning the practical aspects of sclerotherapy, ambulatory phlebectomy, and advanced endovenous laser and radiofrequency procedures. In addition, the American College of Phlebology, the American Venous Forum, the American Academy of Dermatology and the American Academy of Dermatologic Surgery offer excellent courses and seminars as well as live patient workshops at their annual meetings and teach elementary courses at the annual ACP meetings. Newer technologies are much less expensive than older, bulkier machines, running from $20,000 to $50,000, and many are computer-based with excellent visualization capabilities.

Purchase of required capital equipment and facility upgrades can be substantial.

individuals already working in this field or send individuals to paraprofessional training courses such as those offered at the ACP’s annual meeting. Adding equipment as a capital expense represents another challenge in transitioning a dermatology practice into phlebology. The cost of both external and internal endovenous laser and radiofrequency technologies is quite significant. In addition, a significant amount of excess training is required to operate these technologies.The dermatologist considering this major transition must find out if he has a potential source of patients who will fit this practice model. If not, alternative approaches include renting these intermediate and advanced techniques in phlebology. The ACP has set up a traveling Walter de Groot Fellowship, through which practitioners such as dermatologists can have two-week blocks of sponsored educational observation either in the United States or abroad. In addition, the ACP has established a one- or two-year fellowship giving physicians a chance to spend this period of time in an approved academic facility learning all the advanced techniques of phlebology. Such individuals will be eligible for taking the recently advanced board certification exam as well as for fellowship status in this prestigious organization. Learning duplex ultrasound is an important skill set for dermatologists wanting a full-service sophisticated, phlebology practice. It is a skill that requires time, education and practice. Even though most phlebologists have licensed ultrasound technicians in their practices, the dermatologist wishing to expand his practice in the phlebology realm and establish his expertise should read simplex ultrasound guides and textbooks as well as take practical laser radiofrequency technology workshops from vendors that Continued on page 52 provide these mobile programs. Advanced courses and training are the cornerstones of incorporating phlebology into a dermatology practice

Hiring and training RNs, MAs, PAs, nurse practitioners and duplex technicians is another challenge in transitioning a dermatology practice to phlebology. One can look for

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New Treatment Paradigm for Venous Stasis Ulcers A

By Barbara S. Zuniga, M.D. It has been estimated that the health-care expenditures for venous stasis ulcers in the United States amount to an astounding $3 billion per year. In addition, venous stasis ulcers cause the loss of approximately two million working days per year in the United States, and probably 10 times that worldwide. The likelihood of developing a venous stasis ulcer (VSU) increases with age and the prevalence of VSUs in the United States is about 0.3 percent, which translates into about 900,000 individuals affected by this painful, debilitating chronic disease. MEDICAL SCIENCE SLOGS ALONG Medical science has not done a great job with chronic wound healing in general, and this is especially true for venous stasis ulcers. The healing rates for VSUs are typically poor, with up to 50 percent of venous ulcers open and unhealed for nine months or longer. Venous ulcer recurrence rates are also troubling, with up to one-third of treated patients experiencing four or more episodes of recurrence. Adding to this problem is the fact that the clinical management of advanced varicose veins and severe chronic venous insufficiency (CVI) is poorly understood by most clinicians. This is mostly because of the fact that venous disease in general is under-represented in most clinical textbooks, medical school curricula and residency programs. As a consequence, when a patient with CVI and varicose veins develops a venous ulceration, the patient often finds his care to be uncoordinated and full of conflicting (and often ill-informed) opinions, not facts.

approach was logical and prudent in its time â&#x20AC;&#x201D; no reasonable surgeon would subject his or her patient to the drastically increased risk of a serious wound infection by subjecting him to a vein stripping in the presence of an open, colonized or even infected venous stasis ulcer. This paradigm, however, created a bit of a clinical dilemma; Why would we want to delay the definitive treatment of the underlying cause of the ulcer? Wouldnâ&#x20AC;&#x2122;t the ulcer heal more rapidly if we aggressively treated the varicose veins? This clinical dilemma was often managed by non-intervention, often with a focus on what dressing was applied to the wound. With improved understanding based on ultrasound assessment and the advent of new techniques and technologies to definitively treat chronic venous hypertension with truly minimally invasive means, the focus is now on the underlying macrocirculatory cause of the ulceration. Early intervention to reduce the venous hypertension is often in order to speed the process of wound healing. Barbara S. Zuniga, M.D.

THE STANDARD PARADIGM For many years, the standard approach to venous stasis ulcers has been compression bandages of various types, with dressings applied to help moisturize wounds that are too dry, dry wounds that are too moist, kill bacteria, or debride mechanically as needed. The constant part of all standard treatment regimes has always included compression bandages, with off-loading and elevation designed to alleviate edema, and compression management of edema is still an appropriate mainstay of treatment. For many years, another important part of the standard algorithm was to delay any treatment of the underlying varicose veins until the ulcer had healed. The rationale for this

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A venous ulcer present for five years.

A NEW, ENDOVENOUS PARADIGM With the emergence of endovenous techniques and technologies, this clinical dilemma has now been solved. The fact that venous hypertension can be quickly and definitively treated without any significant surgical intervention has made the need for any delay of the treatment of the underlying cause of the VSU totally unnecessary. The literature now contains several small series of rapid healing of venous stasis ulcers after endovenous thermal ablation. Instead of waiting for the ulcer to heal and then possibly treating the varicose veins and venous hypertension, the new paradigm is to treat the venous hypertension with thermal ablation promptly and continue with compression bandages, judicious debridements and good local wound care. As with any form of therapy, not everyone responds in the same way, but the case illustrated to the right is very typical of the rapid healing seen in patients with axial reflux and VSUs.

The ulcer healed two weeks after endovenous thermal ablation of the patient’s short saphenous vein. Note the decreased ankle and foot edema.

Dr. Zuniga is the medical director of the Midwest Vein Center in Orland Park, Ill.

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ACP Joins AMA Specialty and Service Society By Michael P. Krusch, M.D., FACPh Nearly two decades ago, a handful of individuals interested in advancing the science of venous disease joined together to found the organization now known as the American College of Phlebology (ACP). Our founders could not have imagined how far we would come. In November 2005, the American Medical Association (AMA) recognized phlebology as a new medical specialty. In just two short years, phlebology has yet again reached another milestone. Last November, the ACP was admitted into the AMAâ&#x20AC;&#x2122;s Specialty and Service Society (SSS). What this means is that the ACP is now recognized as the national organization that speaks for vein disease specialists. The AMA is an organization made up of member physicians throughout the United States. Each year, these physicians are asked to select a medical specialty society they would like to represent them and their interests within organized medicine. Much like the U.S. House of Representatives, each Dr. Mauriello AMA member society is given a certain number of seats within its House of Delegates based on the number of AMA members a given society represents. The House of Delegates votes on a variety of issues, policies and positions that affect physicians, their patients and the overall practice of medicine within the United States. The AMA House of Delegates is made up of representatives from its constituent member specialty societies. Until now, phlebologists were forced to choose some other medical specialty society to represent them. For example, phlebologists initially trained in internal medicine would likely designate the American College of Physicians as their representative society. Now phlebologists have made the first step toward full representation in organized medicine and can select the American College of Phlebology as the society they would like to represent them.

Phlebologists now have a national voice in health-care policy. This voice will grow as the membership in the College increases. It is imparitive that all vein disease specialists not only join the ACP but also join the AMA and designate their primary or secondary specialty as phlebology. The more AMA members designate themselves as phlebologists, the more clout phlebologists will have in organized medicine. In a few short years, the ACP will be eligible to hold a seat in the AMA House of Delegates. This is the ultimate goal of any organized medical society. A seat in the AMA House of Delegates allows the member society to sponsor bills, resolutions and amendments on key issues facing medicine today. Additionally, it affords member societies representation in a host of AMA committees, including the RUC (RVS update committee), which determines how procedures and their corresponding CPT Codes are valued. In todayâ&#x20AC;&#x2122;s health-care environment, there are many outside influences that interfere with our ability to take care of our patients adequetly. Without a strong voice within organized medicine, we often feel powerless to deal with the abuses of health insurance companies and Medicare or the seemingly unyielding policies of government agencies such as the FDA. By speaking with one voice, we can transform the field of phlebology within the American healthcare system.

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Michael P. Krusch, M.D., FACPh Board of Directors, American College of Phlebology; ACP Representative to AMA Specialty and Service Society

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Medical Diary

Tucson, Arizona Hosts the Annual Phlebology Congress of North America

By John Mauriello, M.D., FACPh The 21st Annual Congress of the American College of Phlebology (ACP) was held Nov. 8â&#x20AC;&#x201C;11 at the JW Marriott Starr Pass Resort & Spa in Tucson, Arizona. Cradled in the mountains overlooking the Tucson Valley, the area called Starr Pass is rich in culture, history and natural beauty. With more than 1,030 in attendance from 27 countries, the ACP congress has become the largest phlebology meeting in North America. Considered to be the premier annual social/educational forum for the diagnosis and management of venous disease, the event attracts an international gathering of phlebologists who come to see old friends, meet new ones and discuss the latest developments in this expanding medical field.

On Wednesday, the day before the meeting, the ACP Foundation held its second annual golf tournament. Played on the Arnold Palmer signature Starr Pass Country Club course, this was a Sonoran Desert luxury golf experience with natural, beautiful surroundings both challenging the players and calming their souls. The congress began on Nov. 8th with four simultaneous pre-congress sessions. Two pre-congress symposia offered comprehensive introductions to the fields of phlebology and venous ultrasonography. The afternoon workshops included live patient evaluations and duplex assessment as well as treatment discussions and video demonstrations of various procedures. Professor Hugo Partsch came from Austria to teach a pair of compression bandaging workshops, and Karen Zupko of Chicago presented a dynamic practice management course providing tips on running a more profitable practice.

John Mauriello, M.D., FACPh

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The congress started each morning with four simultaneous interactive sessions.These early eye openers allowed participants to interact with the faculty in a more personal manner. Topics included sclerotherapy; phlebectomy; thermal ablation; case presentations; treatment of hands, feet, chest and face; and dealing with pelvic veins.

This Honorary Membership Award is conferred upon those individuals throughout the world who have made outstanding contributions to the diagnosis, management or understanding of venous disorders.

Beside the abstract and poster presentations, there were eight instructional courses and 10 symposia The faculty of the congress was entirely that covered the basic as well as the Professor Hugo Partsch (left), Dr. Stefano Ricci (right) and guest at the congress. made up of nationally and internationally newest scientific and practical clinical recognized leaders in the education and information available. No one, no advancement of phlebology. matter what their level of experience, was disappointed. If you missed the meeting or just want An international abstract selection committee of six doctors to review certain parts of it, the ACP, which partnered (four national and two international) reviewed more than 80 with Digitell, Inc., produced a CD-ROM that includes abstracts from 17 countries. Submissions were judged in a the live audio recordings and most of the presentation blind fashion on originality, scientific merit, importance to materials of each session. The conference is also available phlebology and conclusions. Twenty-two submissions were through the ACP Online Library, which offers unlimited accepted for oral presentation and 39 for poster presentations. streaming, downloadable audio (MP3 format), downloadable Dr. Ken Harper won the top abstract award with his paper on presentation materials “The Effect of 3 Month Mandatory Conservative Treatment (PDF format) and 24-7 with Compression Hose Therapy on Quality of Life Issues and instant access. Please see Great Saphenous Vein (GSV) Reflux.” the ACP Web site www. Dr. Neil Piller, the keynote speaker came from Australia, phlebology.org, under the and enthusiastically updated us on lymphatic dysfunctionInformation for Medical recognition and reaction. Dr. Marlin Schul was given the Professional/meetings link JOBST Phlebology Research Award for his project, entitled for more information. “Quality of Life Comparison of Sclerotherapy vs. Compression Stockings for Patients With Isolated Reticular Vein Reflux: A Randomized Trial.” Dr. Van Cheng received the Walter P. de Groot, M.D., Clinical Phlebology Fellowship Award. She reported on foam sclerotherapy as used in London, Nice, France and Istanbul, Turkey. The 13th ACP Honorary Membership Award was given to Dr. Stefano Ricci of Rome.

Continued on page 54

Dr.Van Cheng, with Dr. Lowell Kabnick, proudly displays the Walter P. de Groot, M.D., Clinical Phlebology Fellowship Award she received at the APC meeting.

Dr. Charles Rogers on the left, Dr. Morrison in the center, and Dr. James McEown on the right at the congress.

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about ybeal Laura Gra Tom Sides

Kristin Nicolett i Joseph G . Magn a nt, M.D David S . veen

.D.

Keating, M

ams Megan Willi n, RN so ri Terri Mor n, M.D. so ri Nick Mor nn, M.D oph Wollma Jan-Christ

Kristin Nic oletti Greg Evans Julie Berry

Ali Jahangiri Kristin Nicoletti

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town

VEIN launched at the American College of Phlebologyâ&#x20AC;&#x2122;s 21st Annual Congress, held Nov. 8 â&#x20AC;&#x201C;11 at the Marriot Star Pass Resort & Spa in Tucson, Arizona. The event drew more than 750 attendees and 150 exhibitors. Some 60 doctors attended the congress from aboad. VEIN and veindirectory.org presented the ACP a donation of $25,000 as part of its support for education and outreach.

, M.D. Steven Zimmet M.D. Helane Fronek,

Ali Jahangiri Steven Zimmet, M.D. Kristin Nicoletti

Lowell S. K abnick, M .D. and Steven Zimm et, M.D.

an, M.D. Ali Jahangiri Boyd E. Erdm Schul, M.D. John Mangold Marlin W. Bruce Sanders John Welch

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F E AT U R E D D O C TO R

Tailor-Made Practice

ADVANCED VEIN CENTER’S BRUCE HOYLE, M.D., FINDS HOPE IN NEW TRENDS Bruce R. Hoyle, M.D., medical director of the Advanced Vein Center in Orange, Calif., treats a wide spectrum of vein complaints, including those concerning facial, breast and hand veins. A graduate of the University of Western Ontario and an active member of the American College of Phlebology, Dr. Hoyle recently discussed the vein profession with VEIN’s David DelVal. What are some of the challenges of your profession? Probably the biggest professional challenges are convincing insurance companies of the medical necessity of treating varicose veins and venous insufficiency. I think insurance companies are often skeptical on this point and tend to regard these vein disorders as primarily cosmetic in nature. I don’t disagree there is often an overlap between the cosmetic and medical nature of vein disorders. Insurance companies pay for the treatment of pain. If the condition is not painful, their conclusion is such treatment is cosmetic in nature and, therefore, not a covered benefit. No insurance company pays for the treatment of spider veins. Such treatment has always been considered cosmetic. The reality is that even spider veins can be symptomatic, with complaints such as burning or aching. These complaints will resolve with the treatment of the spider veins.

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What are some of the tough recommendations you have made for certain venous diseases? Probably the toughest recommendation is telling the patient that there is nothing you can do for them. While the treatment of vein disorders has advanced considerably in the last several years, patients with chronic venous hypertension (reflux or venous insufficiency in the deep veins), have very few options. For the majority of these patients, the best advice you can give them is to wear graduated compression hose as much as possible for the rest of their life. Is there a particular case that stands out in your mind? A middle-aged man came to see me from the San Diego area, about 120 miles away. He had a large wound on his lower leg about four inches in diameter. The wound had been present for three to four years. He had been part of an HMO, and, while they recognized this as a manifestation of venous insufficiency, his only treatment had been the prescription of compression hose. He did not have insurance, but his leg looked so bad, we decided to treat him pro bono. After about four treatments that were conducted over a period of eight weeks, we had his leg healed. He worked at a bakery, so on his last visit he brought us some fresh bread, but it was the smile on his face that made it all worthwhile. What are some of the new trends that you think will be popular in the treatment of varicose veins in the near future? One of the newest trends is the treatment of incompetent perforator veins by radiofrequency or laser ablation. Incompetent perforators have historically been a problem. Historically, incompetent perforators have been treated either surgically or by injections of various sclerosing agents using a liquid, or more recently, a foamed preparation. In the last year or so, there has been increasing use of radiofrequency or laser to ablate the perforator. Which venous diseases might be avoided with persistence and care? How might they be avoided? Many vein disorders are hereditary. Since we can’t choose our parents, there is little to be done in this regard. Spider veins and varicose veins certainly may run “in the family.” These can be aggravated by conditions such as obesity, occupations that involve prolonged standing and, in the case

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Leave a Lasting Impression Hand veins can be complex

of women, pregnancies. However, there are vein disorders that are acquired, and some potentially debilitating ones are the long-term consequence of blood clots in the veins. When someone gets a blood clot in a vein, the valves can be destroyed, leading to long-term venous insufficiency, and if this involves the deep system of veins, there are significant longterm consequences. So, the message is to do all that you can to protect yourself from blood clots. This involves regular exercise, keeping hydrated, use of graduated compression hose and doing leg exercises on long car rides or air flights. Have you read any recent medical studies that intrigued you? If so, what were they? I think there is more interest in venous disease than ever before. The cause of varicose veins is still being researched. We know there is a hereditary component involving the type of collagen that supports the vein walls. This may lead to failure of the vein valves. There is also research that suggests inflammation both in the veins and even in the skin around the ankles may be involved in the process. Gene therapy is an exciting field. It offers the hope of potentially curing many diseases that have an inherited nature. Someday, maybe there will be a drug or treatment that can prevent the development of varicose veins. For more information about the Advanced Vein Center, please visit www.advancedveincare.us.

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VEIN NEWS AND

The seven directors of the Board are:

NEW PRODUCTS Craig F. Feied, M.D., FACEP, FAAEM, FACPh

Compiled by VEIN Staff Vein Associates of America Inc. Announces Acquisition Vein Associates of America, Inc. (VNAA), based Heathrow, Fla., has acquired North Texas Vascular and Varicose Veins, based in Plano, Texas, and entered into a managing services agreement with the owner of the vein disease treating clinic, Mark A. McQuaid, M.D., PA. A fellow of the American College of Surgeons, who is board certified in surgery, Dr. McQuaid is a member of the Society for Vascular Ultrasound, the Dallas County Medical Society, the Texas Medical Association and the American Medical Association. He started his practice upon returning to North Dallas in 1996. Dr. McQuaid received his Bachelor’s degree in biology from the University of Texas in Austin and then acquired his Medical degree from Southwestern Medical School in Dallas. He trained in general and vascular surgery at the University of Tennessee in Memphis. During his chief resident year he was the “Outstanding Resident in Laparoscopy” with a special focus on advanced laparoscopy including, laparoscopic herniorraphy and anti-reflux procedures. He was inducted into the American College of Surgeons in 2002. “I’m excited about the opportunity to partner up with Dr. McQuaid,” said John R. Kingsley, M.D., FACS, chairman of the VNAA. “I helped train him in this field, and he has shown on his own accord just how much he has learned along the way about quality of care and the fact that his patients come first.”

Independent Specialty Board to Be Created for Phlebology A significant step in the recognition and acceptance of phlebology, as well as a means to improve standards of patient care is underway. A group of notable phlebologists recently announced the formation of the American Board of Phlebology (ABPh).

Professor of Emergency Medicine, Georgetown University School of Medicine; Director of the ER One Institutes for Innovation in Medicine in Washington, D.C., including the Institute for Medical Informatics, the Institute for Public Health and Emergency Readiness, the Center for Biologic Counterterrorism and Emerging Diseases, the Medical Media Lab, the Simulation and Training Environment Lab, the Institute for Nursing Innovation and the ER One Design Institute; PastPresident, American College of Phlebology. Peter Gloviczki, M.D., FACS Professor of Surgery and Chair, Division of Vascular Surgery, Mayo Clinic; Director, Gonda Vascular Center, Mayo Clinic, Past President, American Venous Forum.

B. B. (Byung-Boong) Lee, M.D., Ph.D., FACS Professor of Surgery, Georgetown University School of Medicine; Clinical Professor of Surgery, Uniformed Services University of the Health Sciences; Emeritus Chairman and Founder, Department of Surgery, Samsung Medical Center & SungKyunKwan University; Founder, CVM Clinic and Lymphedema Clinic, Seoul, Korea; Former Clinical (Visiting) Professor of Surgery, Johns Hopkins University School of Medicine Robert J. Min, M.D., MBA, FACPh, FSIR Acting Chairman of Radiology, Associate Attending Radiologist, Associate Professor of Radiology, Weill Cornell Medical College; President, American College of Phlebology.

Submissions to VEIN News and New Products should be e-mailed to mag@veindirectory.org. Please include the event or product name, pertinent details and contact information. Inclusion is subject to available space.

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Tri H. Nguyen, M.D., FACPh Associate Professor, University of Texas MD Anderson Cancer Center, Dermatology; Director of Mohs Micrographic and Dermatologic Surgery, University of Texas MD Anderson Cancer Center Suresh Vedantham, M.D. Associate Professor, Radiology, Washington University School of Medicine; Associate Professor, Surgery, Interventional Radiology Section, Washington University School of Medicine

Steven E. Zimmet, M.D., RVT, FACPh North American Editor, Phlebology, Past President, ACP

Midwest Vein Center Opens Third Office In Metro-Chicago Area Midwest Vein Center, which operates clinics providing non-surgical treatment of vein disorders in the Illinois cities of Downers Grove and Glenview, has opened a third office in Orland Park. The new location, at 14315 S. 108th Ave., will be run by Barbara S. Zuniga, M.D.. Dr. Zuniga earned her medical degree from the University of Oklahoma and completed her residency at the Tulane Medical Center in New Orleans. Recently, she completed a fellowship training in phlebology. Dr. Zuniga reportedly is the first female physician in metropolitan Chicago to dedicate her practice to vein care as a full-time phlebologist. She is an active member of the American College of Phlebology, the Illinois State Medical Society and the American Medical Association. “My goal is to serve the Orland Park community in the best manner possible, combining the newest technologies with solid scientific data in all aspects of vein care,” said Dr. Zuniga. “Seeking treatment, whether for medical or cosmetic purposes, can be intimidating in the best of circumstances. That’s why a patient’s comfort and satisfaction are of utmost importance to me.”

For more information about the American Board of Phlebology, please visit www.americanboardofphlebology.org or call (510) 834-6500.

VNUS Medical Technologies Names Senior V.P. of R&D VNUS Medical Technologies Inc., based in San Jose, Calif., has appointed Kirti Kamdar senior vice president of research and development. Kamdar, who previously served as senior vice president at Cardiac Dimensions Inc., has 20 years of experience in the medical device industry. Before entering the medical industry, he earned a Master’s degree in polymer engineering and science from the New Jersey Institute of Technology and an executive Master’s degree in Business Administration from the University of Houston.

Midwest Vein Center’s new facility in Orland Park will be run by Barbara S. Zuniga, M.D.

“Kirti’s broad R&D expertise in catheters, radiofrequency products and polymer science is enhanced by his broad skills in clinical and regulatory affairs as well as quality systems,” said VNUS President and Chief Executive Brian Farley. “These combined skills along with Kirti’s long track record of bringing many successful medical devices to the market and in leading research and development organizations, make him a highly welcome addition to the VNUS organization and senior management team.”

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DESIGN CORNER

Medical Co-Op

Reinvigorates Age-Old Interior By Susan Belknapp Not your typical medical offices, California Vein Specialists and About Face Medical Aesthetics are two medical businesses that have flourished as a result of combining their assets. Founded in 2001 by Kenneth Jesser, M.D., and J. Michael Leary, M.D., FACEP, the medical firm now has three offices throughout Southern California: in Palm Desert, La Quinta and Newport Beach. The Newport Beach office, at 400 Westminster Ave., occupies a coveted location on a V-shaped corner adjacent to the illustrious Hoag Hospital, just a few blocks from Newport Harbor. The pre-WWII building underwent some dramatic renovations in order to house the medical offices, treatment rooms and training center.

Dr. Leary, recognized for his skill in performing endoveanous laser treatments, is Diomed Laser’s only national physician trainer in California. Physicians from all over the United States come to these offices to be trained by Dr. Leary. Practice Manager Wendy Metzger headed the recent interior design makeover. “The trick is to bring warmth and comfort to a sterile environment,” says Metzger. “Because first and foremost, this is a surgical center.” California Vein Specialists provides a broad range of medical and cosmetic vein treatments, including laser therapy, sclerotherapy, large and small varicose vein procedures, and elimination of spider veins and veins on the face. About

California Vein Specialists and About Face Co-Exist in Medical Space and Design Ideas

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Face Medical Aesthetics provides skin rejuvination, wrinkle removal, scar and acne treatments, cosmetic injectables and therapeutic massage. Starting with the lobby, Metzger chose to showcase the historic feel of the building, with its large windows, plaster walls, asymmetric angles and original moldings. “I wanted to create a welcoming environment that didn’t say, ‘doctor’s office,’” says Metzger. “Our patients should feel at ease from the moment they arrive.” She achieved this by utilizing the office’s abundant natural light and contrasting the tile floors with overstuffed chairs and an earth-toned sofa. Wooden tables, a black wood wall unit and bamboo trees–which symbolize good luck–give the room a decidedly Moroccan feel. The fluid angles of the furniture complement the clean, natural lines of the plants. Two straight-backed leather chairs on the opposite side of the room anchor the area. Glass tea-light candleholders and decorative accents provide homey touches. “We decorate for every holiday,” says Metzger. On this day, pink-and-red Valentine’s hearts dangle from the ceiling. A flat-screen TV is suspended on the main wall to inform patients and prospective patients about the revolutionary treatments available at California Vein Specialists and About Face Medical Aesthetics. Large floral paintings on canvas line either side of the main hallway. “We are in the process of creating a ‘before and after’ gallery along one wall,” says Metzger. Each treatment room is decorated with the comfort of the patient in mind. The massage therapy room has muted lighting and a cozy décor. Metzger uses fresh flowers and touches of whimsy to keep the atmosphere bright. Opaque nylon-clad acrylic legs are placed on high shelves as a type of “representative sculpture.”

a metal cart; the display monitor is a large flat-screen in the corner, which gives the doctor, assistants and trainees an unprecedented view of the procedures. Because of Dr. Leary’s status as a national trainer, he frequently has several doctors observing and learning the intricate treatments, and they need full viewing access. With the small monitor of the earlier system, this was next to impossible. “This makes it so much more comfortable and functional as a training facility,” says Metzger. “This way, everyone can see without crowding each other or the patient.” Metzger and Dr. Leary credit the uniqueness of the building for much of the office’s overall charm. “People really seem to respond to this old building,” says Dr. Leary. “I don’t know if it’s the permanence or the unusual touches, but it seems to foster a sense of comfort for our patients.”

Top right: Medical technology meets all the comforts of home. Center: Contemporary floral art brightens the hallways. Lower right: Bamboo plants provide a relaxing atmosphere.

The surgical treatment room was the most difficult,” says Metzger. “And it’s still a work in progress.” A mounted fish tank, vases and knickknacks on carved shelves give a touch of color and texture to the hygienic atmosphere. The white wooden blinds, which line an entire wall, are accented with decorative cloth tape in a rich brown. “One thing that made [the treatment room] infinitely more functional is our new ultrasound system,” says Dr. Leary, who specializes in sclerotherapy. “The previous setup was the size of a refrigerator, tethered by cables and wires.” The current system is essentially a laptop, which is maneuvered easily on

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Rounding the horn: Find your turning point for a successful vein practice

Many physicians have tried to build outpatient varicose vein practices but have failed to be financially successful. There are numerous factors that can contribute to low volume practices, such as failed marketing efforts, inefficient work flow, and poorly trained staff. One of the top obstacles preventing physicians from entering the venous market is the lack of time and resources. Many physicians already have an active practice in other specialties, which detracts from the time necessary to develop this unique sub-specialty. In addressing these physician obstacles, interviews of several thriving vein practices nationwide have revealed seven common themes responsible for their success.

Trained Staff: Often, the first person that a prospective patient interacts with is the front office staff. A positive first impression when first entering the practice can make all the difference for the new patient who is nervous about having a procedure. Healthcare staff who are knowledgeable about the procedures and can competently answer patient questions are worth their weight in gold. While training starts with the front office, all healthcare staff benefit from quality education and training, especially ultrasound diagnostics, which is the most important accurate tool for a venous practice. Marketing: There is more to a successful vein practice than skillfully performing procedures. The yield that a top-shelf marketing campaign can bring cannot be underestimated. Effectively marketing your practice can be the difference between performing 2 procedures per week versus performing 20 procedures per week. Industry leading physicians emphasize that the key to successful marketing is to match your marketing to the needs of the target audience1,2 Experts agree that establishing name recognition or a brand for your practice is essential1,2. Going halfway on marketing can dilute your value in the eyes of the prospective patient. Tracking: How can you know where you are going if you donâ&#x20AC;&#x2122;t know where you have been? Analyzing patient conversion rates and marketing strategies aids practice owners in identifying which efforts are effective and which are not. Successful practices track items such as where patient referrals originated as well as the number of referrals converted to procedures. Tracking each aspect of your practice

can be a tremendous utility in identifying ways to enhance your practice. Referral Network: Getting patients in the door can be a matter of having a viable referral network from professionals in your community. Referrals are all about relationships. Invest the time and effort that it takes for other professionals to send patients your way. Clinical Workflow: Every practice knows what a workflow bottleneck can do to office practice efficiency, patient satisfaction, and ultimately patient volume. Find out what is causing patients to wait. Identifying these bottlenecks can save time, money, and frustration for both patients and staff. Find out what is causing patients to wait. Patient-Friendly Environment: The setting for your practice speaks volumes about the quality of your services and the type of care your patients are going to receive. Patients are consumers. They want luxury for what they consider a â&#x20AC;&#x153;cosmeticâ&#x20AC;? procedure. An office suite or medical spa that is designed to put the patient at ease can make a big difference in where patients seek care. Superior customer service: Each and every contact with a patient, whether by telephone, e-mail or in person, sends a message about your quality care. It is important to remember that treating veins is an elective procedure and patients are coming to your practice voluntarily. Each patient needs to be valued and treated with exceptional service and care.

Most physicians trying to start or optimize a vein practice are busy clinicians and can profit from existing models and resources. Rather than reinvent the wheel, many have an advantage when using professional consulting group that can offer customized techniques to assist in jumpstarting a practice. Each market presents unique challenges and therefore, every practice will have different pathways to success. Consultants experienced in the business of growing vein practices with industry knowledge and professional connections can be an efficient option when time is the most valuable asset. A practice enhancement company can provide the clinical and professional expertise to analyze your practice to save you time and resources. For more information, please contact Vanishing Veins at info@myvanishingveins.com or call toll free at 1-877-208-VEIN (8346)

â&#x20AC;&#x153;We partnered with Vanishing Veins because we knew they were one of the industry leaders in the treatment of venous disease and we wanted to grow our vein practice. We were on average, scheduling 10-20 consults a month but could not seem to break the 20 consult mark. Once we partnered with Vanishing Veins and implemented their marketing and practice enhancement programs, we immediately saw an impact. Now we consistently schedule up to 30 consults per month and have the support of a national company to sustain our numbers. I would recommend the Vanishing Veins membership program to all practices interested in improving their numbers without the large capital cost that traditionally comes with consulting and marketing program.â&#x20AC;? Dr. Jeremy Weiss

1. Smith R. 2005. Conversation with Robert J. Min, MD, MBA: Vein Ablation [online]. Imaging Economics March 2005. Available from: http://www.imagingeconomics.com/issues/articles/2005-03_01.asp [Accessed 13 February 2008]. 2. Kabnick LS. 2004. Marketing Your Outpatient Vein Practice. Presented at the Midwest Institute for Interventional Therapy Seminar, October 30, 2004.

IVC to Hold Clinical Sessions for Vein Surgeons By David DelVal

The sixth annual meeting of the International Vein Congress (IVC) will be held April 17–19, 2008, at the InterContinental Hotel in Miami. Among the physicians who annually attend the event are vascular surgeons, interventional radiologists, general surgeons, plastic surgeons and dermatologists, as well as interventional cardiologists and cardiothoracic surgeons. Additional attendees include physician assistants, nurses, technologists and other medical professionals. All attendees, be they veterans of the event or newcomers, share the desire to expand their knowledge in their chosen area of interest.

According to Alexandra Pecharich, the director of communications for Complete Conference Management, the CME provider of the course, more than 500 vein specialists attend the event annually. The attendees are an international lot, Ms. Pecharich indicated. The 2007 attendees, for instance, represented 44 states and 17 countries. Physicians attending IVC receive up to 21.5 AMA PRA Category 1 credits. “All attendees receive educational materials and can apply the hours spent in participation in the meeting toward their continuing medical education requirements,” Pecharich said, adding that the IVC exhibit hall is annually sold out. With more than 40 vendors, the exhibit hall offers the ideal venue for attendees and vendors to exchange information about the latest technology and services that will enhance practices, she added. This year’s topic will cover anesthesia, ultrasound and other advanced technology. Each year, Course Director Jose I. Almeida, M.D., updates the course material to make it relevant for even those who attend regularly, Pecharich said. Additionally, the course covers secondary services and other procedures for which demand continues to grow and which can make an important contribution to individual practices.

At IVC 2007, faculty members included such well-known experts as (from left to right) Drs. Robert J. Min, Alan Dietzek, Thomas M. Proebstle and John Bergan. Dr. Jose Almeida, course director, stands at the podium.

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IVC features a full exhibit hall showcasing the latest technology and offering attendees a first-hand opportunity to learn what is new on the market.

VEIN’s David DelVal recently caught up with vein specialist Philip R. Seaver, Jr., M.D., who provided us with some feedback on his plans to attend this year’s event. How many years have you attended the IVC Annual Meeting? This will be my second IVC meeting in Miami. I heard about IVC from Ron Bush, M.D., one of my mentors in phlebology. I looked on the Internet and found a good balance of practical, didactic and scientific presentations with further practical workshops and decided this forum was exactly what I wanted for my practice. I have also attended other local meetings focusing on venous disease. What especially interests you about this year’s conference? I look forward to learning new techniques and changes in the practice of phlebology over the previous year. Especially important are the new technologies used to perform the venous procedures that lead to better patient satisfaction. I am interested in workshops on marketing and adding to the services provided by my practice.

“Discussion of business aspects, such as marketing and liability, complement the highlighted clinical applications and teach attendees how to effectively expand their practices,” Pecharich said. The following topics will be discussed during the clinical sessions: basic and advanced endovenous techniques, sclerotherapy and light/laser therapy of small veins, saphenous and nonsaphenous vein issues; deep vein thrombosis and hypercoagulable states. In addition, optional mini-symposia—open only to IVC registrants for an additional fee—will cover optimizing the vein center vascular laboratory; cosmetic procedures for the office-based venous surgeon; sclerotherapy symposium and the complete office-based endovascular center. For additional information about the IVC and its annual meeting, please visit www.ivconline.org.

The InterContinental Hotel in Miami

What are some of the challenges of your profession? One of the biggest challenges is dealing with the insurance companies to provide more appropriate reimbursement for the procedures now done in office. We are saving the companies significant money by not using the hospital or ambulatory surgery centers but are inadequately reimbursed. As a result, the excess payment required by the patient leads them to cancel their treatments, even where medically necessary. The fact that many insurance companies reimburse at rates less than Medicare says it all. The companies no longer look at the costs in given areas of the country, but rather base their allowables on the need to increase their profits. The insurance companies define “criteria” for coverage to apply, frequently without any medical basis. More and more physicians become nonparticipating, resulting in limitation of access to the venous procedures, which can be life-altering. Philip R. Seaver, Jr., M.D., is a board-certified vascular and cardiothoracic surgeon and a fellow of the American College of Surgeons, American College of Phlebology and American College of Chest Physicians.

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P H L E B O L O G Y I N T E R N AT I O N A L

International Phlebology Report

For the inauguration of this new column, VEIN’s Claudia Schou recently caught up with renowned phlebology expert Eberhard Rabe, M.D., to get an inside perspective of European phlebology practice as well as an update on the German Society of Phlebology. What is the history of phlebology in Germany? The first phlebological organization in Germany was the Association of Specialists for Leg Diseases, which lasted between 1909 and 1934. It was founded by Dr. Bertold Lasker, first husband of the famous writer Else Lasker-Schueler, and by Dr. Nathan Brann. After the Second World War, the German Society of Phlebology was founded in Frankfurt [on March 23rd, 1957]. The first president was Erich Krieg, who was also the first president of the Union Internationale de Phlébologie (UIP), which was founded 10 years later in 1967. Since then, the society has grown steadily and now has about 1,300 members. What are the key initiatives/goals of the German Society of Phlebology in the next five years? In the last two decades, phlebology has changed from “experience-based medicine” to “evidence-based medicine,” but there are still a lot steps to go. This is one of the main goals of the German Society of Phlebology. We are encouraging and funding scientific studies and projects in diagnosis and treatment of venous diseases. This includes new less-invasive treatment options for varicose veins, genetics of varicose veins, venous ulcer treatment, deep venous thrombosis, phlebitis and epidemiological studies. At the same time, we have to improve education not only of new phlebologists but also of established colleagues in the meaning of continuous education. We also have to encourage young physicians to take the option of phlebological training.

How do most doctors get training in phlebology? As phlebology is a certified subspecialisation in the medical system in Germany, there has been an official education program of one to five years duration since 1992 in addition to specialization in dermatology, internal medicine or surgery. Before 1992, most doctors learned phlebology in continuous education and self-established training programs. In 1985, the German Society of Phlebology established a Collegium of Quality Control, which was a predecessor of the current official subspecialization. What training opportunities are available? There are officially certified institutions in hospitals and private practices that are certified by the health organizations for training in phlebology. Do your colleagues in other areas of medicine recognize phlebology as a specialty? Yes, this is the case. Vascular medicine in Germany is performed by vascular surgeons, angiology is a speciality in internal medicine and phlebology is a subspecialisation in the above-mentioned specialities. The competition between these groups has diminished in the last years, and we are working together quite well. This is partly due to the fact that the members of the German Society of Phlebology belong to different specialty groups, including dermatologists, vascular surgeons and internal medical specialists. Phlebology in Germany is an interdisciplinary matter as represented in our society. Is phlebology taught in medical school and residency programs? Phlebology is not one of the main specialities. The education in medical school differs from university to university. It is usually integrated in the dermatological, surgical or internal medical lectures, but, in most cases there is no phlebological lecture covering the whole field. Is there a certification program in Germany? As phlebology is a certified subspecialization, there is an official certification program, lasting one to five years, of theoretical and practical education in a residency program.

Eberhard Rabe, M.D.

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Who delivers phlebology care in Germany? Different medical specialists like dermatologists, internal medical doctors, surgeons and vascular surgeons perform phlebology as a subspecialty.

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This includes clinical, duplex and functional investigations of the superficial and deep venous system; conservative and invasive treatment (sclerotherapy, surgery) of superficial venous diseases; and diagnosis and treatment of lymphedema. Does insurance cover phlebology procedures? What is the process? Health insurance covers the majority of phlebology procedures in Germany. This only excludes treatment for cosmetic reasons, like sclerotherapy of spider veins. Compression treatment, sclerotherapy and surgery are reimbursed. There is only a discussion concerning new treatment options like endovenous procedures and foam sclerotherapy, which are not yet integrated in the official reimbursement system. What are the trends in phlebology in Germany? Concerning varicose veins, as everywhere in the world, less-invasive systems like endovenous laser treatment or radiofrequency treatment of varicose veins is of growing interest. The same is true for foam sclerotherapy, which has already reduced the number of operations, for instance, in recurrent varicose veins. Concerning deep venous diseases, ambulatory treatment of deep venous thrombosis has been established 10 years ago, and we are looking forward to new anticoagulation drugs. You are the current president of the International Union of Phlebology. Can you discuss the UIP and what the goals of the organization are? The Union International de Phlébologie is the union of about 40 national societies all over the world. The aims of the UIP are to strengthen the links between the societies or associations, either existing or to be created, which have a special interest in the study and the therapy of venous disorders; to create recommendations regarding the teaching of phlebology as well as the training and continuing medical education of phlebologists; to promote consensus on all aspects of venous disorders; and to encourage studies and research on disorders of venous origin.The goal is also to promote joint meetings and international congresses, to encourage the creation and activities of national societies or associations, and to encourage them to join the International Union of Phlebology.

fields of phlebology. We are also developing a communication platform with a worldwide newsletter service. The next UIP World Congress will be organized by the German Society of Phlebology and the French Society of Phlebology together in Monaco on August 31st to September 4th 2009. What are the trends that you see internationally? Internationally, phlebology gains more and more interest which leads to the formation of new phlebological societies. In former decades, phlebologists usually belonged to a small subgroup in other societies in fields like cardiovascular surgery or dermatology. As a consequence, phlebological topics were integrated in the national congresses of these societies more or less intensively. In some countries–like the USA, Germany, France or Italy–societies dedicated only to phlebology were created from the beginning. Now, more and more, young societies are developing with this goal. This is also caused by the fact that populations are changing in the western countries towards a higher proportion of aged people with a higher prevalence of venous diseases. In other countries, prosperity increases with a higher income in the general population and, consequently, a better chance to finance the treatment of diseases that are not life-threatening. At the same time, phlebology has become more and more evidence-based in its diagnostic and therapeutic options. Treatment of varicose veins has become much less invasive and, in many countries, treatment of venous diseases has changed from vascular surgical procedures towards endovascular treatment. But we still have to solve many questions. We still don’t know why varicose veins develop and which genetic changes predispose for this disease.

In summary the three goals of the UIP are: 1) To improve scientific work in phlebology; 2) To improve education in phlebology and 3) To improve communication between the phlebological and other vascular societies The UIP organizes world congresses every four years and supranational chapter meetings between these periods. Until 2009, we are building up a curriculum in phlebology, which should be the basis for national curricula and education systems. For this reason we are organizing several consensus documents in all www . veindire c tory . org

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Education in Phlebology Getting Beyond the Basics by Steve Elias, M.D., FACS

Many times, education and learning involve doing things we’ve never done and sometimes even doing things we don’t want to do. Yet we trust those who have experience and believe that when we are done with the education experience, it will be for our benefit and our patients’ benefit. Those of us involved with phlebology come from diverse backgrounds. Our foundations and skills are different, but we all hope to achieve the goal of being able to manage problems in a cohesive and somewhat similar manner.

Steve Elias, M.D., FACS

This monthly series of articles will touch on the many various routes and opportunities available to become what we all want to be: competent phlebologists.

Medical/surgical training traditionally has been a glorified apprenticeship. You learn by observing and being taught by those who already have some experience. They know a lot, but they don’t know everything. They teach you what they know. But with every teaching cycle, there are students who ultimately surpass their teachers. Those students elevate us to the next level.

uncomfortable will be your best asset. Training and education involve this concept. If you can’t be comfortable doing something you’ve never done before, then you may never get beyond the basics. Education is a process that takes you from a safety zone to an uncertain zone and back to a new safety zone. It is up to your teachers to make you as comfortable with a new procedure or new technique as you can be. But until you’ve done a few on your own, a certain anxiety level will be there. That’s okay. How to minimize the uncomfortable feeling is what we hope to explore over the next few months– getting comfortable with feeling uncomfortable. As an example, we started “The Annual Fellows Course in Venous Disease” two years ago to fill a void in vascular fellowship training. Most vascular fellows gain a large amount of experience with arterial disease and arterial endovascular procedures. A few training programs highlight venous disease, most do not. This statement could probably be applied to most training programs: medical, surgical, interventional radiology, dermatology, etc. We felt a two and one-half day course specifically directed toward the unique needs and open attitude of vascular fellows would be beneficial. This is an industry-sponsored event with all fellows’ expenses covered. The attendees are limited to 35 fellows and eight faculty members. All aspects of vein disease are covered. The course is interactive and responsive to the fellows’ needs, such as core knowledge, technical expertise and practice development. For them, learning new techniques and concepts

“Just take this big clamp, and place it on the aorta.Then close it, and stop the blood flow to the lower half of the patient’s body.” Does this sound logical or reasonable? Of course not, but this is what your teachers (vascular surgeons) tell you to do when you do an open aortic aneurysm resection. As crazy as it seems, it usually works. The point is: You’re not the first one to do this. You may feel uncomfortable doing this, but you do it because the person teaching you has told you it’s OK. Education and learning involve a leap of faith at times. When first starting a “vein practice,” there are so many things to consider. At times, feeling comfortable with feeling

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is a natural extension of their training. They are the easiest to educate because they hold minimal preconceived ideas. For many reasons, the course has been well received and successful. The courses for 2008 will be held at the Englewood Hospital and Medical Center in New Jersey and at the Cleveland Clinic in Ohio. Early education is key to specialty growth and well-trained specialists. The other end of the spectrum is teaching new ideas to physicians who have been in practice. For the past seven years, I have participated as faculty or director of many types of educational programs attended by physicians interested in venous disease. Most of the attendees have some preconceived notions of vein disease management. In the beginning, many felt the newer minimally invasive procedures wouldn’t ever work. The academics, in general, were the most skeptical.

…with every teaching cycle there are students who ultimately surpass their teachers. Those students elevate us to the next level. My attitude is to always adopt the concept: “Respect the elders, embrace the new, encourage the improbable and impractical, without bias.” How else can we ever progress if we think what is the best is what is? So as open as young physicians are, experienced physicians tend to want to stay in their comfort zone and do what they know. It is much harder to get practicing physicians to be “early adopters” of new techniques or technologies. Many physicians need to be shown long-term data regarding efficacy and safety. Phlebology is in a state of flux. There are many courses addressing the needs of practicing physicians to obtain sufficient core knowledge. Once we reach the tipping point of having enough people educated, it will become a more self-propagating specialty. Long term, the goal is to make courses such as the “Fellows Course in Venous Disease” obsolete. Knowledge about venous disease will be incorporated into the training programs of those specialists who see patients with vein disease. It is up to the various professional organizations and interested industries to begin a process to achieve the goal of comprehensive venous training. Some have already, such as the American College of Phlebology, which inaugurated a fellowship in 2007. All involved will need to get comfortable with feeling uncomfortable. Steve Elias, M.D., FACS, is member of the American Venous Forum, the American College of Phlebology, the Society for Clinical Vascular Surgery and the International Society of Cardiovascular Surgery. He currently serves as director of The Center for Vein Disease at Mount Sinai Medical Center in New York and director of the Center for Vein Disease at Englewood Hospital and Medical Center.

Catheter Tips for Beginners By Wayne Gradman, M.D. 1. A wedge or blanket under the contralateral hip helps your patient maintain eversion of the treated leg for an extended time 2. A warm blanket is my favorite way to dilate the venous system. Use a heating blanket to heat the blankets you put on the patient before you start. A generous dollop of Nitropaste at the entry site can be of additional help 3. Splurge for a tumescent infiltration pump. It makes administering tumescent anesthesia a breeze. Be generous with anesthetic (200-300cc/thigh length). 4. Stay a small distance from the saphenous vein when infusing tumescent anesthesia into the saphenous fascial compartment. It is possible to infuse the solution into the vein rather than around it. 5. Learn to use shadowing artifact to determine the location and orientation of the sheath.

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ARE YOU NEXT?

Generation Next PAC is a network of young business and community leaders committed to making a difference by empowering individuals and causes to provide long-term solutions that will better our individual and collective futures. Our forward thinking and cutting edge approach, combined with our extensive resources, provide a platform for advocates who represent the center-right voice of the Next Generation of Americans.

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V E I N I N D U S T RY RESOURCES SPOTLIGHT

BSN Medical Inc. Places Focus on Style and Appeal With JOBST Brand

By Dean J. Bender, Vice President R & D

VEIN is pleased to launch a new column written by medical industry professionals who want to let our readers know about their vein industry-related business. VEIN wishes to not only highlight medical industry professionals but also become a guide for vein industry resources. BSN Medical, formed in 2001, is a global manufacturer and distributor of medical textile products, servicing the wound care, orthopedic, phlebology and lymphology markets. BSN is best known in the United States for the JOBST brand of medical compression garments. JOBST is the No. 1 provider of medical compression garments in the world, with a complete offering for all stages and aspects of venous and lymphatic disease. The JOBST product portfolio contains compression bandaging, anti-embolism stockings, medical gradient stockings, custom-knit and custom-sewn garments for severe venous and lymphatic disease, arm sleeves, gloves, and gauntlets–not to mention surgical bras and other specialties needed to provide the most complete therapy options for our patients. JOBST currently has manufacturers for medical compression products in Germany, France, the United States and Mexico. JOBST’s heritage of investment in the advancement of therapies for venous and lymphatic disease originated in the late 1940s with the founder Conrad Jobst. Jobst was a renowned mechanical engineer working in Toledo, Ohio, when he was left essentially disabled as a result of the development of venous ulcers.The therapies of the day were unsuccessful in treating

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his condition, and had it not been for his own realization one day in a swimming pool about countering the internal venous hypertension with external compression, he most surely would have lost his legs to amputation. The initial innovation of the JOBST products came in the development of textile processes designed to create garments that could provide external gradient compression to the lower limbs. While we have seen over the years significant improvements in the fibers, fabrics and styles of gradient compression garments, the basic underlying premise remains unchanged. The industry of medical compression garments has seen significant change in the past 10 to15 years with a concerted effort by JOBST and other manufacturers to design and develop medical compression garments that not only meet the medical need of providing external compression but also improve the therapeutic index of the products–that is, innovations that reduce the adverse effects of the products. Medical compression stockings have the reputation of having the “Mrs. Doubtfire” styling and appeal. They have traditionally been perceived as “ugly,” “hot,” and “uncomfortable” and, of course, quite difficult to don. This has led to poor patient compliance and a reduced therapeutic outcome. However, today it is now possible to be wearing medical compression stockings with no one recognizing thier presence.

Dean J. Bender

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JOBST produces mens support socks for a wide-ranging clientele.

or the soft supple fabrics found in “Opaque.” The men have not been left out either; products designed specifically to meet their fashion requirements can be found in the “For Men” catagory. The latest advancements from the JOBST team have focused not only on the fashion segment of our patients’ needs, but also on the need for compression in a casual environment. Our recently released “Women’s Casual” and “Activewear” products further add to the concept that medical compression garments can now allow patients to blend into their environments without the stigma of everyone knowing they are wearing a medical device. The next generation of products to be rolled out by the JOBST team is designed to improve the comfort of wearing compression stockings. Significant developments in textile technology in regards to improving the moisture management of textile fabrics has resulted in the creation of garments that move moisture away from the body, improve the evaporation rate, and reduce the relative humidity

between the body and the fabric, resulting in a more comfortable wearing experience. This comfort enhancement can already be seen in the JOBST “Activewear” medical stocking– available in 15-20, 20-30 and 30-40 mmHg compression–which incorporates “DriRelease” (Optimer™) fiber technology. Such advancement has been seen in products targeting venous disease patients as well as in our “Elvarex” product line for the therapy of lymphedema. Recently released in Europe and coming to the United States, the new line of “Elvarex Soft” products provides the excellent edema management in a softer, more easily donned fabric design. At JOBST, we recognize that our patients would prefer not to be faced with the challenges of managing venous and lymphatic disease. It is our objective to see to it that compression therapy continues to provide optimal therapeutic outcomes while making the experience as pleasurable as possible.

Ramirez International, exceeding client expectations

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Sciatic Nerve Varices By Jose I. Almeida, M.D., FACS, RVT

Sciatic nerve varices are an uncommon condition. However, those involved in the care of patients with venous disease should have some familiarity with this condition. There is a dearth of information in the literature referable to sciatic nerve varices. Therefore, this article will present personal experience, communication with others and small published case series. Appropriately, sciatic nerve varices were categorized into “nonsaphenous reflux” by Labropoulos et al. These veins were described in vulvar; gluteal; lateral; posterior thigh; popliteal fossa; and in lateral knee areas. They were defined as superficial veins that are not part of the greater or lesser saphenous systems. Nonsaphenous venous (NSV) reflux was found in 72 patients and 84 of 835 limbs (10 percent) examined with duplex ultrasound. Of the 84 limbs with NSV, incompetent veins from the sciatic nerve were found in nine (10 percent). Of the entire NSV reflux group, 93 percent were women, and most were women with at least three pregnancies.1

growth of the femoral vein, the axial vein normally involutes, with remnants persisting as the sciatic veins of the glutei and satellite vein of the sciatic nerve. In the aforementioned study by Labropoulos, nine limbs (10 percent) and seven limbs (8 percent) were found to have reflux in the veins of the sciatic nerve and the popliteal fossa, respectively, both of which may be easily mistaken for the small saphenous vein. However, pain often accompanies reflux of the former because it may stimulate the sciatic nerve. In symptomatic persons, distinguishing the true anatomic site of reflux is necessary to facilitate appropriate and effective treatment. Signs and symptoms assigned to CEAP classes one to three were found in 90 percent of limbs.

Nonsaphenous veins are imaged best in the standing position using 4-MHz to 12-MHz linear array transducers. Occassionally, a 3 MHz phased array transducer was used to track the connection of the nonsaphenous veins with the deep system.

Therefore, the cause of NSV reflux disease may be found in physiologic factors unique to women. Hormonal variation during progression from the onset of menses through menopause and during pregnancy provides stimuli unique to the female. It is, therefore, plausible that isolated NSV reflux disease, uncommon in men, is an entity predominantly found in women because of a sex-specific mechanism of etiology.

No image of ultrasound provided

Although the embryologic development of the arterial system of the lower limb is well described, this is not true of the venous system. Within weeks of the axial artery’s development, a peripheral border vein provides venous outflow from the limb bud. Ultimately, the tibial continuation of this disappears and the fibula portion becomes the anterior tibial, lesser saphenous, and inferior gluteal veins. The retroperitoneal postcardinal vein gives rise to the greater saphenous vein, which gives off the femoral and posterior tibial veins.2 The axial artery in utero is paired with an axial venous network, which may provide a source of collateral venous outflow in the presence of deep venous obstruction.3 Within

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Notably, differences in clinical severity of NSV reflux and saphenous reflux are apparent. In a previous study of 250 consecutive limbs, 92 percent were found to have superficial reflux, and 37 percent were found to have skin damage, as compared with only 10 percent of 84 limbs with NSV reflux alone. The incidence of skin damage is significantly decreased in isolated NSV reflux (P< .0001).4 We have only seen a handful of cases of significant sciatic nerve varices warranting treatment at the Miami Vein Center in the last decade. These patients presented with debilitating pain and visible posterior thigh and calf varicose veins. Our treatment of choice is ultrasound-guided sclerotherapy with 1.5 percent Sotradecyl Sulfate, with or without adjunctive ambulatory phlebectomy. Typically, one or more venous channels are sonographically identifiable in close proximity to the sciatic nerve. The veins are accessed percutaneously with the patient in the prone position. Because of the subsequent inflammatory response incited by sclerotherapy, we avoid treating veins adherent to the sciatic nerve. The results have been satisfactory in the few patients we have treated. Mel Rosenblatt, M.D., presented his experience at the Sonoma Venous Anti-Conference last year using fluoroscopicguided sclerotherapy for the treatment of sciatic nerve varices. He also noted multiple venous channels resembling a “horsetail” by fluoroscopy and cautioned against overzealous treatment. He did see one sciatic neuropraxia postprocedure that resolved without sequlae. Sciatic nerve varices are uncommon; present with pain, usually in multiparous women; and are treatable with sclerotherapy. Access can be obtained with either ultrasound or fluoroscopic imaging. Extreme care is necessary during treatment because of the close proximity of the sciatic nerve. Jose I. Almeida, M.D., FACS, RVT is the founder of the Miami Vein Center and a voluntary assistant professor of surgery at the University of Miami School of Medicine. REFERENCES: 1. Labropoulos N, Tiongson J, Pryor L, Tassiopoulos AK, Kang SS, Mansour MA, et al. Nonsaphenous superﬁcial vein reﬂux. J Vasc Surg 2001;34:872-7. Surg 1997;84(Suppl):68. 2. Trigaux JP, Vanbeers BE, Delchambre FE, de Fays FM, Schoevaerdts JC. Sciatic venous drainage demonstrated by varicography in patients with a patent deep venous drainage system. Cardiovasc Intervent Radiol 1989;12:103-6. 3. Arey LB. The vascular system. In: Arey LB, editor. Developmental anatomy. 7th ed. Philadelphia: WB Saunders; 1974. p. 342-74. 4. Labropoulos N, Kang SS, Mansour MA, Giannoukas AD, Buckman J, Baker WH. Primary superficial reflux with competent saphenous trunk. Eur J Vasc Endovasc Surg 1999;18:201-6.

Lawrence Illuminates the Way

for Phlebology’s Future

Peter Lawrence, M.D., is fine-tuning what he believes is a significant discovery in the treatment of venous disease. Lawrence, who serves as chief of vascular surgery at the University of California at Los Angeles, has learned through clinical studies how to treat varicose veins with a new procedure called Light-Assisted Stab Phlebectomy (LASP). His study, which first appeared in the October 2007 issue of the journal, The American Surgeon, relied on more than 250 patients who underwent the procedure to remove branch varicose veins from the thighs, calves and ankles. The technique combines powered phlebectomy and stab phlebotomy along with transilllumination. For the latter, a light source is placed beneath the skin to aid in highlighting the veins during the procedure. The patient is sedated prior to treatment but remains conscious during the LASP procedure, Dr. Lawrence said. A tiny incision is made near the varicose veins. A slender tube with a light source at its tip is then threaded underneath the vein cluster. To provide further anesthetic and to make the veins readily visible, a mixture of saline, lidocaine and epinephrine is infused into the area. With the operating room lights turned off, Dr. Lawrence can now see the veins illuminated under the skin. “This is one of the first times that transillumination is used during the actual vein-removal procedure, which offers maximum visibility for the surgeon,” Dr. Lawrence said. “Usually the veins are mapped before the procedure, which is not as effective.” Lawrence said the procedure may provide lower residual varicose vein occurrence due to the greater ease in identifying the veins in the operating room through transillumination. The next step is a larger study and longer follow-up with patients, he added. Dr. Lawrence is the director of the Gonda (Goldschmied) Vascular Center at the David Geffen School of Medicine at UCLA.

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Phlebology into Derma practice Automated pumps are necessary when tumescent anesthesia is contemplated for ambulatory phlebectomy and endovenous procedures. Setting up a designated suite is an important aspect of good standard practice and specialization of patient care in phlebology. A designated suite where all sclerosants and compression garments are localized facilitates treatment access to the phlebology patient. If you are transitioning to surgical procedures, a designated ambulatory operating room is suggested. With increased regulation coming down the pike, the dermatologist/phlebologist should consider OR certification as part of his practice-building plans. To begin letting patients know your dermatology practice now has a subspecialization in phlebology, adequate educational and marketing materials should be available for patients in the waiting room areas. Such materials may be self-generated or taken from the ACP. Finally, as the dermatologist reaches the summit of his or her transition to phlebology, a board certification process has recently been established through the American ACP (see the ACP Web site: www.phlebology.org). Broad Challenges of Incorporating Phlebology Into a Dermatology Practice The pros of incorporating phlebology into a dermatology practice that has been previously outlined include professional advancement, increased patient referral and economic practice expansion.

The major challenges in this setting are office reorganization, including personnel changes; time set aside for advanced training and educational courses; financial investment in practice diversification and advancement; and patient education â&#x20AC;&#x201D; the introduction to the full scope of phlebology services that are being offered in your practice. However, all of these challenges are easily surmountable for those dermatologists willing to transition themselves into establishing a world-class phlebology practice. Conclusion Incorporating phlebology into a dermatology practice is a rewarding, realistic goal for the practitioner interested in venous disease and motivated to expand his or her professional skills, expertise and career. Increased physician and patient outcomes are the ultimate results of this lofty, rewarding endeavor. Dr. Sadick, M.D., FACPh, holds four board certifications: Dermatology, Cosmetic Surgery, Internal Medicine and Hair Transplantation. He has authored more than 500 articles in peerreviewed scientific journals and has contibuted more than 75 chapters of medical books. He practices at two Sadick Dermatology locations in New York.

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Medical Diary, Arizona The author (right) with the13th ACP Honorary Membership Award recipient Dr. Stefano Ricci of Rome (left).

Dr. Marlin Schul giving his presentation.

Trip Todd, M.D., FACPh has already started planning for this year’s ACP congress, which will be held Nov. 6–9 at the Marco Island Marriott Resort Golf & Spa in Marco Island, Fla. He assured me that the next congress will be even bigger and better. Start planning now to attend this extraordinary annual event. A call for abstracts, video and poster presentations will be posted on the ACP Web site www.phlebology.org in early spring. I hope to see you all at the 22nd annual ACP congress in Marco Island, Fla.

Keynote speaker Neil Piller M.D. (left) and Proffesor Hugo Partsch (right).

John Mauriello, M.D., FACPh is a board member and the treasurer of the ACP. He practices at Vein Associates of America’s office in Lake Mary, Fla.

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