Message from the Editor

Time Is a Jet Plane

Is the term “jet plane” an oxymoron or just not right? When we travel in 2022 most of us get on a jet. But we probably text our loved ones, “getting on the plane now.” Why the improper use of the word “plane”? I don’t know. When we see someone with a DVT most of us ask, “Have you taken a long plane ride recently?” This is relatively unlikely. Not too many commercial plane flights around. How awkward would the words, “Have you taken a long jet ride recently?” sound. Unless your patient is Chuck Yeager. He flew a lot of jets, but Chuck is dead so don’t worry; you won’t be seeing him.

It is the 16th century and the French word jeter emerged. It is derived from the Late Latin word lectare meaning to throw, to toss, impel. By the way, the first jet was the German Messerschmidt ME 62. Those Germans. Along with the jet came “jet lag,” the greatly feared ailment of many travelers. But let’s get back to what started these thoughts, Bob Dylan’s words in the song You’re A Big Girl Now: “time is a jet plane, it moves too fast,” Time is not a jet plane and it doesn’t move too fast. What was the man thinking? Well, to be fair, many times no one quite knows what the man was thinking. All I know is that most upscale magazines, websites, and the New York Times seem to be obsessed with time and watches.

If you want to know the exact time, just look at your phone. If you want to enjoy the visual, emotive sensation of time, look at your watch. Not your everyday, plebeian, plain watch, but your overpriced, unnecessary watch: Rolex, Vacheron Constantine, Panerai, Hublot, IWC, etc. Unnecessary, but coveted by some. Peruse any of the upscale magazines, websites or the New York Times and see a multitude of advertisements for these unnecessary but apparently needed watches to tell you the same time that your cell phone does. Maybe time is not the only point.

This issue of Vein Specialist doesn’t have you wonder, “What is the point?” We tell you: membership. This issue is member centric. Bill Marston’s letter basically tells us what AVF members have been doing for the AVF. A lot has been accomplished this year, but nothing could have been accomplished without member involvement, time, effort. A very personal letter by Pavel Kabrik succinctly tells us what new members experience when they join. Don’t underestimate your impact on new members. In life, sooner or later, it is all personal. Fellows and Early Career members or potential members are where the majority of our growth will come from. Misaki Kiguchi lets us know how successful the most recent Seattle Fellows/Early Career course was. And it was fun. It could not have happened without industry support. Antonio Solano writes about what our members of the Social Media Committee have been doing. They have been doing a lot. Our social media presence is key to involving our members in 2023 and beyond. The old days are just about over. The Healthy Veins Book is finished. John Blebea interviewed by Beverly Chan tells us how it was conceived and how it was completed. Again, a work by many members giving their time. Finally, we hear from our international members – Latin America, Egypt/Africa, Europe, and Ukraine. AVF has a lot of OUS members contributing a lot to AVF. It is time all members understand that even though our name includes the word “American,” about 25% of our members are OUS.

Speaking of time, is it time to understand which US cities have a rat problem? You know those rats. Scary creatures with a bad rap. Chicago, NYC, and Los Angeles lead the list of those with a rat problem. Not surprising, a lot of people want to live in these cities; I guess the rats do as well. I’ve never seen a rat. Nasty, scary, aggressive creatures. Really? Maybe not. They are relatively smart as far as nasty, scary, aggressive creatures can be. They have been trained to successfully search for earthquake and landmine victims. I just don’t want to think about what the rats do once they find the victims. And so we have come full circle, the oxymoron: jet plane, nice rats. Contradictory terms that may mean something in the right context. We hope this issue has reinforced the AVF concept of unity and focus of purpose: our members and the pursuit of science. No one is an oxymoron. The image of time as a jet plane moving too fast with Dylan wearing a Panerai watch being tracked down by predatory rats in NYC may seem incomprehensible. This issue of Vein Specialist is not. It keeps you grounded, focused, and safe from the ravages of time and rats. Take a breath. Relax. You’ve got time and there are no rats. See you at the annual meeting with our fellow members.  

Message from the President

Serving as president of the entire membership of the American Venous Forum is a tremendous honor.  I have always considered the AVF to be the pinnacle of venous research and science. Since my early days in the society, I have learned so much from members and leaders of the AVF who were excellent mentors to me. I am very excited about the current status of the Forum and the potential we have in the coming years to grow the capabilities, influence, and impact of our society.

In the past year, under the leadership of President Tony Gasparis and Executive Director John Forbes, the AVF has made great strides in expanding its educational offerings, establishing a strong operational base, and diversifying income sources to be less dependent on industry. As a result of the energetic leadership of your Board of Directors, our committees, and our outstanding staff, a number of impactful programs were developed and brought to fruition. Among them are:

As we continue to work on these and other important projects, as well as prepare for VENOUS2023, I would like to highlight a major emphasis for the current year. As you are aware, patients with venous disease are diverse in many ways and clinicians interested in the treatment of venous/lymphatic disease are becoming increasingly diverse. AVF leadership believes that it is critically important for the Forum to support diversity, equity, and inclusion in its fundamental core values. A new ad hoc DEI committee was established earlier this year, co-chaired by Drs Ruth Bush and Kathleen Ozsvath. The committee is examining all aspects of AVF operations, programs, and initiatives to identify areas for support and improvement of our DEI goals. VENOUS2023 will have a significant focus on DEI with specific sessions throughout the meeting including research and discussions related to the management of venous disease in diverse populations. Diversity among those presenting information to the Forum will also be a significant focus in planning.

Reflection on AVF Membership

As someone who was recently placed on the AVF’s Membership Committee, I began to look back on how I became a member of the AVF.

As a student, I had the opportunity to begin research in venous disease. At that time, vascular surgery was a relatively new field to me, and I knew even less about the venous disease aspect of the field. The people who first got me interested in vascular surgery and, particularly, in venous disease were Drs Anil Hingorani and Enrico Ascher. They introduced me to the American Venous Forum, which I joined in 2019. At the time, I believed it would help further my interest in the venous field through what I learned by going to meetings and getting more exposure which I could then translate to clinical practice in the future– along with furthering my research interests.

As an AVF member, I have further learned of all the benefits of being a member. The AVF has helped me increase my interest in the venous disease realm of vascular surgery, helped me find mentors such as Dr Windsor Ting, and experience various educational benefits. Being around those who have similar interests in the venous field in terms of research and helping advance the care of patients with venous disease has become the most valuable aspect of being part of the society. A particular area of interest, which I believe anyone interested in vascular surgery should have, is chronic venous insufficiency. Given how prevalent it is in the population and the need for physicians and allied health members, including those outside of vascular surgery, to recognize the disease process makes it a growing priority.

I would like to invite anyone with an interest in treating venous and lymphatic disease, both physicians and allied health members alike along with students who wish to become vascular surgeons, to consider joining the American Venous Forum. By becoming a member of the AVF, you will reap the benefits of being of a member of this society, which can be used for the rest of your career.

Join the AVF by November 30, 2022 to receive the following bonuses*:

• $100 off AVF membership dues for 2023. Includes up to 3 free months of membership. Membership will be valid through December 31, 2023.
  Enter this discount code at application checkout: BAM!2022
• Choice of $125 discount for VENOUS2023 registration OR$100 coupon for ShopAVF.

*New member bonuses are limited to new Physician Members (National & International) and Recent Graduate Members.

Learn more here.

Fellows Course Highlights

The AVF Fellows and Early Career Course and the West Coast Vein Forum this year took place at the same time and same venue on September 22-24 at the Edgewater Hotel in Seattle, Washington. The Fellows Course had 56 participants including faculty. As has been tradition, each fellow was able to attend free of cost – thanks to the support of our industry partners and AVF.

The AVF Early Career Committee planned a unique case-based learning environment that allowed constant interaction between faculty and fellows in a unique, intimate, small-group setting. From Dr Steve Elias’s running around the room asking fellows, “What would you do?” to Dr Carson and Dr Kiguchi’s discussing practical solutions to complications of superficial vein treatments in their own practices, the sessions were filled with lively discussion. Drs Attaran, Harth, and Hedayati all provided excellent talks on “tips and tricks” phlebectomy, current VTE guidelines, and how to choose one superficial venous ablation technique over another. Their enthusiasm in teaching these young fellows was palpable. Thanks to all of the speakers who devoted their time in preparation and attending!

Thank you to our sponsors

DID YOU MISS THIS EVENT?

The 5th West Coast Vein Forum (WCVF) was held in Seattle September 22-24 – this time in parallel with the Fall Fellows and Early Career Course in the same venue. The Early Career course was well-attended; the WCVF less so.  But despite smaller numbers, everyone had a great experience. Our headliner faculty at WCVF included Drs Kathy Gibson, Fedor Lurie, Bill Marston, and Mark Meissner. Their spectacular presentations taught me that those involved with research have a special insight into the rest of the scientific literature.  Huge thanks and appreciation to them all.

Knowledge Diffusion through Social Media: Crossroads for Venous Pathology Learning

In past years, social media has allowed people to keep in touch with individuals all around the world. The transmission of information is migrating from newspapers and television to academic and social platforms, supporting globalization of knowledge. Regarding medical practice, trends have shown physicians’ engagement to exchange their own clinical opinion and advise with immediate circulation. In just seconds, Twitter can help you get an answer for your next surgical planning or start debate of current treatment practices between peers. Thus, the technological era poses a wide spectrum of possibilities to enrich venous knowledge.

The AVF Digital Committee created #PollOfTheWeek, an initiative aimed to address daily clinical practice topics as well as discussion of venous pathology guidelines. We want to open a new space for knowledge interchange among colleagues, endorsing continuous learning. From trainees to experienced vascular surgeons, anyone can participate in this online round table. Now, the crossroads for venous pathology learning is just a click away.

Be a part of the conversation – Follow @VenousForum for Twitter!

A New Book for A New Year: The Healthy Veins Book

Dr Beverly Chan, Chair of the AVF Patient Education Committee, interviewed Dr John Blebea, past president of the American Venous Forum, treasurer of American Vein and Lymphatic Society, and clinical professor of vascular surgery at Central Michigan University College of Medicine, about the soon-to-be-published patient-focused The Healthy Veins Book: Understanding Varicose Veins and Leg Swelling.  The full-color, lavishly illustrated 40-chapter book represents the work of 53 authors under Dr Blebea’s editorship and will be available in hardcover and digital formats in December.

Dr Chan: Dr Blebea, you have written more than  250 publications, mentored 3 decades of residents and fellows, and have focused on venous disease throughout your career. Tell Vein Specialist readers what was your inspiration for The Healthy Veins Book.

Dr Blebea: Like most things in medicine, this book builds on the efforts of others in the past. The first edition of the Handbook of Venous and Lymphatic Disorders in 1996 provided the template for the definitive textbook on venous and lymphatic diseases for clinicians. (By the way, the 5th edition will be coming out in 2023, under the editorship of Dr Peter Gloviczki.) It was later thought that a companion resource for patients would also be helpful. Therefore, under the leadership of Drs Michael Dalsing and Gary Lemmon, the AVF developed an on-line book, The Layman’s Handbook of Venous Disorders, with 20 chapters from the clinician’s Handbook adapted and re-written for lay people. This resource was available on our website, but I thought that it was time both for an updated and more comprehensive book specifically written for the public.     

Dr Chan:   So how did it come to fruition?

Dr Blebea: We were fortunate to receive a $50,000 educational grant from the Bristol-Meyers Squibb Foundation to get us started. Since that initial grant, we have received continued support and further funding from the AVF Foundation, which represents the contributions of our members and industry supporters. Needless to say, getting this book written and published required the efforts of many people besides myself. The Healthy Veins Book was made possible because of the tremendous contributions of 53 leading experts in venous disease in the United States and Canada representing 42 different institutions. In addition, we had Ms. Deborah McBride to help with editorial development and publishing, along with the administrative leadership of the American Venous Forum, led by its Executive Director John Forbes and Director of Mission Advancement Jeff Mendola. Multiple companies also graciously allowed our use of images of their products, which will be very helpful to readers.

Dr Chan:  What makes this book different from others already published?

Dr Blebea: There is no other comparable book. It is the only book specifically written for patients with venous disease. At 256 pages in a hard cover format, it provides in its 40 chapters a comprehensive yet understandable review of the entire range of venous disease. We include chapters on the anatomy and pathophysiology of varicose veins, deep venous disease, blood clotting disorders, lymphedema, and pelvic venous insufficiency, among other topics. As would be expected, the natural history and treatment options for each of these disorders are also included. More than 150 color illustrations and diagrams clarify the content.

Dr Chan:  What kind of frustrations do you find with your vein patients when they come to see you? How will this book help?

Dr Blebea: When we see new patients in consultation, we try to explain to them as thoroughly as possible their likely diagnosis and recommendations for treatment. For patients with venous disease, they will often be seen a second time before an interventional procedure. However, present-day clinicians have only a limited amount of time to examine a patient, talk to them about their problem, and complete the inevitable paperwork associated with required documentation and procedure scheduling. Most of us attempt to enhance the patient’s understanding by giving them a copy of a detailed informed consent document– such as those developed by the AVF– or a descriptive brochure. This book will provide patients with a much more detailed and comprehensive explanation of their venous disease and potential treatments. The chapters were specifically written so that they can be read and understood independently of each other. Therefore, a patient being prescribed compression stockings need only read the chapter by Dr Joseph Caprini or someone about to undergo cyanoacrylate adhesive closure the chapters by Drs Allesandra Puggioni and Steve Elias. Each chapter has commonly asked questions that most people have about their venous problem which they often forgot to ask during their office visit. The book also has a detailed Index and Glossary which can be used to quickly look up information that can be found across multiple chapters. All of this makes a wonderful resource for patients and their families to use not just once but repeatedly during their lives.

Dr Chan:  Who should purchase this book?  

Dr Blebea: This book was originally envisioned for laypeople with venous disease to refer to as an objective and comprehensive source of information. While much information is on the internet, most of that information is often procedural advertising. Little of it gives the complete picture of appropriate indications and all the options for treatment. The Healthy Veins Book fills this critical need for objective and complete information. Therefore, people with venous disorders and their caregivers should buy this book.

By extension, The Healthy Veins Book should also be purchased by physicians to make it available to their patients, either at cost or free, depending on the economics of their office practice. Industry should also buy these books in bulk to provide to patients via the physicians utilizing their products, so patients better understand the procedure that they are about to undergo and have realistic expectations of the outcomes.

Dr Chan:  Are there others who would benefit from reading The Healthy Veins Book?

Dr Blebea: Absolutely! It was very interesting that, as the book was coming together, it became evident that The Healthy Veins Book would also be a valuable educational tool for others besides lay people. All of us appreciate that there is very little venous education provided to medical students or general surgery residents. Indeed, even vascular surgery residents and fellows have no required training in venous disease and, in some programs, have no exposure to venous disorders. Trainees in other fields of medicine receive no education about venous disease yet those physicians in primary care are often the first ones that patients with venous insufficiency encounter. Similarly, physician assistants and nursing mid-level practitioners are increasingly taking care of such patients. The Healthy Veins Book would be an excellent teaching tool for all of them. Its coverage of the entire gamut of venous disease would provide them with the knowledge to understand and treat such patients at a primary care level and recognize what additional testing is needed and when referral to a venous specialist is indicated. A chapter on “Further Reading” provides the substantive references that form the basis of the contents of each of the chapters. This would be a great book for all such trainees and health care providers because no other book provides such information at such an accessible level.

Dr Chan:  How can people get the book?

Dr Blebea: The book will be available in January of 2023. However, pre-orders are available now!  AVF members can purchase before December 31 for the reduced price of $22.95. After that, the member price will be $35.95. For non-members, the respective prices will be $29.95 and $44.95. The Healthy Veins Book can be purchased at the AVF Store [ https://store.veinforum.org/ ] The full Table of Contents and a sample chapter will also be viewed. An eBook version will be available via Amazon for $19.95.  

Dr Chan:  What are the future plans for the book?

Dr Blebea: We are presently working on making individual chapters or thematic groups of chapters available for online downloading. This will make it more accessible for individuals who want information just on their particular problem at a reduced price. This online capability will also allow us to update chapters in the future and add additional information on a regular basis.

Dr. Chan:  Any final thoughts? 

Dr Blebea: With Christmas just around the corner, The Healthy Veins Book at a pre-order price of $22.95 would make a wonderful present for family members with venous disease. It would also make a wonderful Christmas gift and a sign of appreciation to our trainees and nursing staff in the office.

Please give a warm welcome to September and October
NEW AVF MEMBERS

On February 24th. A Letter from a Phlebologist from Ukraine

On February 24, I woke up earlier than usual due to a loud TV broadcasting from the neighbor’s apartment.  “The war has started” crossed my mind…. A rapid look into breaking news confirmed reports of multiple missile attacks across the country, Russians crossing the border, and the first victims.

It was not easy to get to work in time that day, as an unexpected number of cars were heading in all directions, Queuing at gas stations and grocery stores made the ride complicated. Literally on top of those difficulties, the sound of air alarms–that were not for training purposes– marked the start of the new reality for every Ukrainian, a grim, painful, and deadly reality.

Invitation to EVF in Berlin 2023

The European Venous Forum, in collaboration with the German Society of Phlebology, is pleased to announce the forthcoming meeting of the European Venous Forum in Berlin in 2023 (June 22nd  to 24th). Berlin is not only the capital of Germany, but a pulsating city full of contrasts, always worthy to be visited! The venue was chosen next to the center of the city–a– 10 min walk to the Parliament and Brandenburger Tor, places of historical importance for Germany and Europe, where World War II was started and the Berlin Wall between East and West was broken.

We chose the Bolle Festsäle as the venue.  Its ancient rooms were the site of the first modern dairy where in the last years of the 19th century milk was delivered by cow carts or little ships.Unbelievable social care was provided to the employees: The owners built a chapel and a party room to allow for festivities of the team members – official and privately. Assuming that external constraints do not change the ability to meet in person,  our meeting will allow a better discussion and  exchange of ideas  in the venue, but also allow us to join industry sponsorsin an exhibition in the wonderful ancient light-flooded dance hall of the dairy.

These historical rooms will provide the backdrop for the presentation of the latest scientific results in phlebology, which are selected by a strong peer review and will provide a good location for vigorous  discussion. Abstract submission will open shortly (https://europeanvenousforum.org/index.php/evf-meeting/abstract-submission/).  Didactic sessions will cover new developments in practical phlebology such as CVD as an occupational disease or the social impact and solutions for phlebologic / lymphologic diseases, as well as the latest results on superficial vein thrombosis,  and endoluminal treatments will be presented.   In addition, the joint session of the American Venous Forum and the EVF will be presented.   

A special highlight is the keynote lecture by Dr Tobias Bertsch who will present the latest results in lipedema investigation and its impact on society.

The congress hotel is next door and many hotels fitting every budget can be found in the surrounding area.

On behalf of the European Venous Forum and as president of the meeting, we warmly invite you to join this high-level scientific phlebology event.

Getting to Know Latin America

Latin America is a big area with very diverse geography, which means different cultures exist even within the same country. This obviously leads to multiple visions of phlebologic and lymphologic treatments conditioned by cultural geographic and economic factors. This situation does not vary significantly from the reality of many countries around the world.

Today in Latin America phlebo-lymphology is performed in general by 3 types of professionals: vascular surgeons, general surgeons who have been mostly dedicated to these pathologies, and phlebo-lymphologists. The predominance of the type of specialist varies according to the place. Each country has one or two scientific phlebology and lymphology societies; more per country is an exception. Regarding accreditation, universities in some countries have phlebology programs that are very complete and offer rich clinical practice. However, there are express courses that certify a specialty but do not really create a specialist.

Venous Leg Ulcers: An Overview

Venous leg ulcers (VLU) are the most common cause of leg ulcers. The prevalence of VLU is reported to be 1-2% among the general population. VLUs account for 50-60% of all leg ulcers, creating a significant healthcare burden. Venous leg ulcers can also cause social and psychological problems, as they can be commonly associated with pain, fatigue, anxiety, and depression.

Venous leg ulcers typically occur in the gaiter area of the leg, around the medial malleolus. They are typically surrounded by darkly pigmented skin. They could be associated with skin hardness (lipodermatosclerosis) and/or varicose veins.  Less frequently, they could be located on the lateral side of the leg or in the foot.

The treatment plan for venous leg ulcers requires an accurate diagnosis of the underlying venous pathology.  The initial investigation is a color-flow duplex scan.  The duplex scan covers both superficial and deep venous systems. The potential sources of reflux in the superficial venous system are scanned with the patient standing. This includes the great saphenous veins (GVS), the accessory saphenous veins, the small saphenous vein (SSV), the incompetent tributaries, and the incompetent perforators.  In addition, we give special attention to scanning the ulcer area for an incompetent network of veins underlying or in the vicinity of the ulcer.  The deep venous system is scanned for evidence of reflux or post-thrombotic occlusion. Every segment of the deep venous system is scanned, starting with the tibial veins at the ankle level up to the inferior vena cava.

Axial imaging such as CTV or MRV could be used if iliac vein or IVC pathology is suspected.

In addition to assessing venous pathology, a non-invasive test could be used to diagnose peripheral ischemia if present since 10-15% of VLU have concomitant arterial pathology.