Seshadri Raju, MD, was trained as a vascular surgeon. He is currently in private practice specializing in venous and lymphatic diseases. Dr. Raju is a founding member of the American Venous Forum, an organization for venous disease, as well as a distinguished fellow of the Society for Vascular Surgery. He is widely published and has spoken at numerous national and international meetings. At the 2016 New Cardiovascular Horizons meeting, Dr. Raju delivered a keynote speech in which he addressed new technologies in venous disease as well as the growing interest in venous therapy among operators previously focusing on only arterial disease. He described the changes that need to occur in order for patients with venous disease to receive effective care. Vascular Disease Management spoke with Dr. Raju about his work.

VDM: Have you observed a growing number of interventional cardiologists or other vascular surgeons become more interested in venous therapy?

Raju: Yes. As they say, “Go West, young man.” It’s a new frontier for multiple specialties.

VDM: What would you like to share with interventionalists who have an interest in treating venous disease?

Raju: New technologies have changed the practice of venous surgery. Venous surgery has evolved into an interventional therapy, in part due to the new technologies available. Also, we used to focus on reflux. We thought it was a main pathology in venous disease. By doing interventions in the veins, we have come to know maybe it’s no longer as important to treat, at least in the deep venous system. Obstruction seems to be equally important. We can put in stents and correct venous obstruction. We don’t have a good interventional solution for reflux yet. But that doesn’t seem to matter. We get rid of the obstruction and patients get better, even with residual reflux.¹

VDM: What are some of the technologies that have made things easier?

Raju: Of course for the superficial systems now you have various kinds of ablation, such as laser or thermal ablation. So that has made a big impact, but some of the more severe manifestations of venous disease, like skin changes or swelling, are generally related to deep venous systems. And we use stents for venous obstruction in the deep system. Stent technology has advanced quite a bit, but there is room for improvement.

VDM: How do you see therapy improving for venous disease? 

Raju: Right now, we go step by step. We start with a superficial system and then if it doesn’t work or that isn’t the main pathology, we go to the deep system. Our diagnostic techniques are not as good as they could be, so there’s improvement in how to look at disease and analyze pathology and choose a more selective way of approaching cases. Right now, it’s all a blanket approach. It’s not selective. I think that can come with improved testing techniques. 

VDM: What kind of challenges have you faced in trying to shoehorn an arterial device into a venous application?

Raju: That’s still happening now. Almost everything we use in the venous system was originally designed for the arterial system. So we make do with that but that’s not a perfect solution. The venous system has a different architecture, different size, different pressures. So we need an entire line of venous-specific products, which we don’t have. There are some companies beginning to look more at venous devices. The number of patients affected by venous disease is probably 2 to 3 times as large as those with arterial disease. We will get dedicated devices, but right now we are not there. 

VDM: What are some of the parameters that would need to change in those devices?

Raju: Most arterial sheaths are smaller. You don’t want to put a big hole in the artery. On the venous side, you can go up to 14 Fr to 16 Fr without too much worry about bleeding complications. Of course if the sheath is bigger, the manipulation becomes easier. It’s the same thing with guidewires. The size can be larger. 

VDM: What is the key takeaway?

Raju: For one, the advent of new minimally invasive technologies has removed open techniques such as valve reconstruction from first-line techniques. Those are now reserved for salvage only. In fact, with proper selection of technique, most venous pathologies can be successfully managed by minimally invasive techniques. And the key takeaway is that the venous system, the venous pathology, is so different from arterial. In some ways, we have to forget what we learned on the arterial system to relearn on the venous system. We cannot fly by the seat of our pants in the venous system just because we know arterial techniques.

Editor’s note: Dr. Raju reports patents for stents and IVUS diagnostic technology and stock ownership with Veniti.

Reference

1. Raju S, Darcey RL, Neglén P. Unexpected major role for venous stenting in deep reflux disease: symptom relief with partial correction of pathology. J Vasc Surg. 2010;51:401-408.