The Evolution of Venous Therapy With Lowell Kabnick, MD, and Jose Almeida, MD

At the 2015 VEITH Symposium, Vascular Disease Management spoke with Lowell Kabnick, MD, and Jose Almeida, MD, co-chairs of the venous programming at the meeting. They describe the pros and cons related to the ways that clinicians from multiple specialties have embraced venous therapy.

Kabnick: Dr. Veith asked us to put on a hands-on workshop here at the VEITH symposium, and it’s called Venous Venous Venous at the VEITH Symposium. This is our inaugural year and it looks really great. It had many vendors in industry but more importantly, the physicians have really anted up in terms of teaching. 

We have about 40 faculty and we probably have 1 faculty per 2 attendees in terms of the number of attendees this year. We have 200 registrants divided into morning and afternoon sessions and we have each session divided into the deep system and one into the superficial system. We also have case discussions. This year, the case discussions went very well and were very informative and they brought a lot of the industry in in terms of the techniques that we use. 

Almeida: In the way of background, VEITH Symposium, which is now its 42nd year, has been a traditional vascular surgery meeting so Dr. Veith asked Lowell and I in 2006 to start a venous session. It started as a dedicated 1-day venous session, mostly didactic with traditional PowerPoint talks, and it slowly morphed into 2 days and 3 days. This is the year that we launched these workshops where attendees get an opportunity to work more directly with industry partners and devices. Both Dr. Kabnick and I are traditional fellowship-trained vascular surgeons who have always felt that veins have been long ignored. Now that venous therapy is being adopted by arterial counterparts and we have almost half the talks in this meeting, I think we’ve done a good job.

Kabnick: We’ve been educating now for 10 years, and we are now coupling that with hands-on “go ask the expert,” so in a particular area of venous disease, there’s an expert sitting at a booth, who you can approach with any questions that you have. I think that’s key. I don’t think there’s any other place you can do that, and in terms of VEITH, that’s novel.

VDM: How has the adoption of venous therapy by vascular specialists evolved?

Almeida: In general, what we call the endovenous revolution started about 15 years ago with the advent of new minimally invasive devices. Before this, we were doing traditional vein stripping, with surgeons in an operating room. There’s some good and some bad that come with change, because the catheter has blurred the line between specialists, so something that was clearly in the realm of a surgeon now with a catheter falls into the realm of multiple specialists. That can be good for access but bad in terms of the different training backgrounds, the way that people do things, and the way they interpret the evidence base. It’s a little bit of heterogeneity that we would like to make more homogeneous with better education, so again there is good in that it’s multispecialty and broadening as a field but bad in that we lose a bit of control in what people are doing and what we would like to see them doing. 

Kabnick: Like everything else, when Jose and I started in the minimally invasive field 19 years ago, it was a little bit difficult. It was challenging. Through the evolution of new products and the development of further generations of the same products, it made it easier for almost everyone to adopt venous therapy. The difficult part is teaching when and why to do something and what results you should expect. Vascular surgeons are trained to meet expectations, basically to do something so that you are helping the patient.

Almeida: Careful patient selection is what we’re talking about.

Kabnick: …and when to do it appropriately. Nowadays, everyone is doing it and some without the proper training, it really makes it difficult for us, but we’re here to help. You can’t expect to learn this in an overnight course, and proper training is the best way to go in terms of venous therapy. Vascular surgery certainly is insightful, interventional radiology is also a way to go, and now interventional cardiology is stepping up.

VDM: How about any specific trends in therapies or devices that you’ve seen over the last year or two? 

Almeida: The last 15 years have really been about the superficial venous system, and as Dr. Kabnick alluded to, refining the products to become even easier for saphenous vein ablation and superficial vein work. Now we’re seeing a similar explosion, I feel it about to pop in the deep venous system. Where before we would only offer a blood thinner and a compression stocking to patients with post-thrombotic syndrome, now we’re really going after these things with devices to try to open obstructed veins and all the challenges that come with that, the device challenges. We have some stents that are off-label, and we need better dedicated stents. 

We need to improve inflow from scarred veins down below, and better ways to open those channels and keep them open. There is a lot of room for improvement, a lot of room for good technology devices. You can feel the energy and that’s where it’s all going right now. It’s about to get big.

Kabnick: As I say, superficial venous disease was a new frontier 15 years ago, because we went from something medieval to something that was minimally invasive. Now we’re seeing the same frontier in deep venous disease with the development of new devices to help us clear thrombosis both centrally and peripherally. More importantly, we haven’t quite gotten there yet where we have one tool that is going to help us do this. We need in our treatment a number of tools. It would be nice to get this down to a minimum. 

There are some new events in terms of lifesaving events, in terms of pulmonary embolism, with catheters that have been developed and this is really evolutionary. Now that certain hospitals have pulmonary embolism teams, and acute DVT teams, we are managing these patients a whole lot better than giving them a pill and seeing what happens. 

VDM: Anything else you think is important to add? 

Almeida: As always, I’d love to congratulate Frank Veith on another wonderful meeting and thank him for giving us the honor and privilege of being his course leaders on the venous side.