myAVLS - 2021 Fall by myAVLS

Veins & A that Jazz Veins & A that Jazz SAVE THE DATE

Catch you down in New Orleans! AVLS 36th Annual Congress

October 13-16, 2022

Hyatt Regency New Orleans & at Home

Table of Contents PRESIDENT’S LETTER........................................................................................................................................................................ 4 FVLD: More than Fundraising.......................................................................................................................................................... 6 GREETINGS FROM YOUR STAFF AT AVLS!............................................................................................................................... 7 STOP CMS’22.......................................................................................................................................................................................... 9 ABVLM 2021 UPDATE.........................................................................................................................................................................14 SPACEFLIGHT RESEARCH: THE POTENTIAL TO IMPROVE WOUND CARE IN OUR CLINICS.............................16 AVLS FELLOWS GIVE BACK!.........................................................................................................................................................23 A RECENT PAPER EXAMINES ULTRASOUND-GUIDED FOAM SCLEROTHERAPY: WHAT IS THE CONSENSUS? WHERE IS MORE RESEARCH NEEDED?.....................................................................................................24 THE KING IS DEAD, LONG LIVE THE KING..............................................................................................................................29 PHLEBECTOMY ZONES IN THE LOWER EXTREMITY........................................................................................................ 30 REPORTING FROM THE AVLS PRO VENOUS REGISTRY BY DR. ROBERT WORTHINGTON-KIRSCH............32 UNDERSTANDING AND APPLYING VENOUS CLASSIFICATION SYSTEMS................................................................33

President’s Letter MyAVLS Magazine • September 2021 • By Dr. Mark Meissner

Here we are at the AVLS Annual Congress in Denver, Colorado, on October 7 – 10, 2021. I want to especially thank all of you that made it a point to attend this year’s meeting in person amidst all of the chaos that continues regarding the pandemic. This is an opportunity to renew old friendships, advance your knowledge of venous and lymphatic disease, and become involved in your society’s activities. I do not want to overlook those of you who chose to attend this year’s Congress virtually. One positive out of the pandemic has been the advancement of technology that enables the AVLS to offer access to the Congress through livestream and on-demand, meaning you never have to miss out on the Congress again! Although the ongoing pandemic has made it impossible for us to meet in person over the past 18 months, it has been a very busy year for the American Vein & Lymphatic Society, with many important achievements by our standing committees and task forces. These have included the publication on a new classification system for pelvic venous disorders, the SVP classification (https://www. myavls.org/svp-classification. html) as well as again partnering with Johns Hopkins University to produce a followup study to the Improving Wisely project. As the PRO

Venous Registry completes migration to a new platform, we anticipate the completion of several scientific projects over the next few months, and the publication of updated guidelines for the management of C2 chronic venous disease (in collaboration with the Society for Vascular Surgery and American Venous Forum) later this year. Several new task forces have also been established to codify the AVLS conflict of interest policy for board members, evaluate coding and payment models for phlebectomy, and evaluate potential pathways to establishing venous and lymphatic medicine as a recognized subspecialty. The collaborative multidisciplinary membership of the American Vein & Lymphatic Society makes it unique among medical societies. Our members, representing multiple disciplines and a variety of practice settings, learn from each other and collectively advance the field of venous 4

and lymphatic medicine. Unfortunately, these special aspects of our society have been challenged over the past year, and the AVLS has developed an active response to them. Foremost among these have been ongoing efforts to establish venous and lymphatic medicine as a recognized specialty and to stop the devastating impact that proposed changes to the Medicare Physician Fee Schedule (MPFS) will have on our member’s practices and our society. Although the American Board of Venous and Lymphatic Medicine (ABVLM) was created in 2007, progress towards recognition by the American Board of Medical Specialties (ABMS) has been slow. Fortunately, our efforts have been recently stimulated by an independent request for the American Board of Surgery to create a focused practice designation (FDP) for general and vascular surgeons. In response, the AVLS has created a task force under

the leadership of Drs. Jeff Schoonover and Zoe Deol with the goals of moving towards ABMS recognition of Venous and Lymphatic Medicine and attaining Accreditation Council for Graduate Medical Education (ACGME) recognition of the ABVLM fellowship programs. The task force has already had several productive calls with ABMS and ACGME administrative staff. This likely will be a multi-year process, but progress is being made towards the recognition our membership deserves. The AVLS Healthcare Policy committee has developed a robust response to the proposed changes in the 2022 Medicare Physician Fee Schedule. As all should be aware through our membership communications, implementing the Proposed Rule would result in a 20% weighted average reimbursement decreases in nine of the most commonly used venous codes. Overall, it is estimated that venous and lymphatic specialists would suffer a 12% decrease in payment across all services between 2021 and 2022. Such dramatic cuts would affect most of our members in officebased practice and threaten the viability of their practices as well as patient access to timely care. Our actions include commissioning two studies evaluating the impact of the proposed rule on our members and their patients by respected third-party analysts, drafting a robust response to CMS, and partnering with the United Specialists for Patient Access (USPA)

to educate and encourage a congressional response should implementation of the Proposed Rule move forward. Unfortunately, the response to this critical situation is costly and lies outside of the usual AVLS budget. However, given the dire consequences that this would have for our members, their practices, and their patients, as well as the multidisciplinary and inclusive nature of our society, the AVLS has initiated an aggressive campaign (STOP CMS’22) to urgently address both the current issue as well future threats to the field of venous and lymphatic medicine. Since 2018, reimbursement for six commonly used venous codes has declined by over 20%, and this progressive erosion will undoubtedly continue. Fighting public policy is a process that involves many small fights and the ability to rapidly respond to such threats quickly. Our initial goal is to prevent the proposed CMS cuts for venous and lymphatic medicine from taking effect on January 1st, 2022, with a long-term goal of preserving equitable venous and lymphatic code valuation and coverage for all eligible patients. Although the Healthcare Policy Committee is doing an outstanding job of responding to the current crisis, we need all of our members to become involved. The thing that I would personally ask of each of our members, Inform – Become informed about how the Proposed Rule will directly impact your 5

patients and practice and what the AVLS is doing to protect your future through the STOP CMS'22 campaign. Invest – Become an AVLS Physician Advocate and donate the equivalent of the reimbursement for one venous ablation - $1200 (although donations in any amount would be greatly appreciated). Donations can be made through the AVLS website at www.myavls.org/cms22 Involve – Take up the cause, volunteer to engage your peers as Physician Advocates and challenge them to donate to the cause and contact their legislators. Engage your members of Congress and convey your concerns for the future of your patients. Inform your Medicare patients and ask them to contact their legislators. Our goal is to raise over $300,000 to fund both this effort and the ongoing reimbursement threats to venous and lymphatic medicine. Your contributions to this important effort will be specifically recognized at our Annual Congress. I look forward to seeing each of you at Congress. In addition to the outstanding educational program developed under the direction of Dr. Robert Worthington-Kirsch and his committee, we can anticipate further discussion of the AVLS advocacy efforts and initial discussions about the next phases in the development of our society.

FVLD: More than Fundraising By Dr. Marlin Schul

The Foundation for Venous & Lymphatic Disease (FVLD) has been in existence for over 16 years, and I am excited to report that the Foundation is still making a significant impact in the field. The FVLD was created initially to support the vision of establishing venous & lymphatic disease as a recognized medical specialty and now is making possible an expanded vision of supporting advocacy, research and education across all facets of the field. event to support the Foundation’s efforts and encourage developing relationships among our membership, I could not help but accept. Now, as we approach our 14th event, I feel so blessed to know that I can still play golf (though not as strong a golfer) with a great group of people who have become friends at previous events.

The FVLD has raised over $12 million over the past 16 years, enabling the field of venous and lymphatic medicine to grow and thrive. When you look back at the various opportunities the FVLD made happen, you will find the creation of the American Board of Venous & Lymphatic Medicine, Venous & Lymphatic Fellowships and the PRO Venous Registry as significant investments that have changed the landscape significantly. More recently, the FVLD has allowed the AVLS to build the resources to be strong advocates on behalf of the specialty. Then you throw in the various educational scholarships, research grants and technology advancements (virtual reality education) among a litany of other activities, and you find that the FVLD has been able to impact the future of each of us that practice in this field.

Each year, the Foundation hosts a variety of social activities around the AVLS Annual Congress that are all designed for us to interact in enjoyable ways outside a classroom, enabling us to develop deeper relationships and share our passions for what we do with each other. Although I love golf, you will find that the Foundation has developed our 2nd Expedition for those that prefer to hike and explore the surrounding areas of our Congress venue. In addition, we have an opportunity to exercise together each Saturday morning of Congress with our Annual Fun Run and Walk. There is no excuse for you not to get involved and begin your adventure with the Society and the Foundation by engaging with each other and developing new relationships and friendships that will last a lifetime.

While I am personally grateful for all that we have accomplished, I want to focus on another aspect of the Foundation that has made a tremendous difference in my life. I was a relatively new member of the Society when the Foundation was created and was just starting to get to know various members beyond seeing their names on publication here and there when I was asked to Chair the 2nd Foundation Golf Outing. Now for those of you that have gotten to know me, I have three passions outside of my work routine: my family, adventure travel, and golf (not always in that order, LOL!). When asked to get involved in an

We all live and practice in challenging times, and it is only when we approach the future together that we can truly make a difference. From my own experience, I can promise you that you will not regret getting involved with the Foundation and changing our future together! 6

GREETINGS FROM YOUR STAFF AT AVLS! Welcome to Denver, CO and the 2021 Annual Congress! We are so excited to be spending time with each of you in person, as it has been two years since the last time we gathered in Phoenix, AZ. So much has transpired since the world turned upside down in early 2020 when this pandemic began, and even today, it seems that we are still taking two steps forward and one step back! But through it all, let me assure each of you that staff and I have felt it a privilege to support the membership through all the various trials we have faced. But let us not dwell on the negative and instead focus on the future in front of us and the opportunities ahead. We are now more than three years into our New Horizon strategy that aims to expand the depth and breadth of our Society beyond our creation as an educational society in the field of superficial venous disease. Over the past three years, we have embraced the Lymphedema community, recognizing that venous and lymphatic medicine are congruous. In addition, our efforts in developing an understanding of pelvic venous disease and other aspects of deep venous disease have resulted in the AVLS becoming the largest, most comprehensive Society in venous and lymphatic medicine in the United States. Furthermore, we expanded our reason for existence beyond education with significant investments in our capability to conduct research and develop clinical practice guidelines designed to help support our dedicated mission to be advocates for our membership, the field in general and most importantly, our patients with payors and policymakers. Our desire has been for you to not only see a new name and logo for the Society but also understand all that our volunteers and staff have invested into this mission to improve the lives and practices of all our members. We have accomplished much but have so much more to do! And if we are going to continue to impact our world, we all must step up, get involved and make a difference. To those of you who have actively volunteered over the past years, thank you! Your willingness to serve has allowed us to accomplish much. And for those of you considering the future, we encourage you and thank you in advance for what you will do in the future! We are now back together, and on behalf of this year’s Congress planning committee, the leadership, and staff of the AVLS, we encourage you to reconnect with your colleagues and take advantage of the opportunity that meeting face-to-face offers. We have worked hard to provide a safe environment for everyone in attendance by social distancing in our conference rooms, requiring all attendees to wear masks regardless of vaccination status, and encouraging proper hygiene. We ask that you all respect each other and enjoy this excellent opportunity to reconnect. Sincerely, Dean J Bender • CEO/Executive Director 7

By Dr. Robert Worthington-Kirsch Chairman, AVLS 2021 Planning Committee

As some of you know, my life priorities start with God, my family and fly-fishing. That’s one of the reasons I am so happy to be planning the meeting here in Denver.

After the meeting, every session is available for online viewing, so we can revisit something we heard live for more detail or attend sessions we didn’t get to during the live meeting.

There are two approaches to fishing a river. When you are wading, you can only cover a small segment of water, but you take the time to pick the segment apart – changing tactics to get the best results from each hole, run, or seam. When you are in a drift boat, you fish in what looks like the best water in a section and are then on to the next section – covering more water but not taking the time to investigate every detail of any section.

I won’t push the metaphor any further, but there are several sessions that everyone will find interesting and valuable. On Thursday morning, our Keynote Speaker is Dr. David Lechner. David is a Medical Director for Blue Cross Blue Shield (BCBS) of Montana and will be sharing with us how the payers need and use the kind of “big data” that the AVLS PRO Registry is generating. David also has a side gig as a drift boat guide.

To me, meetings are usually a lot like a drift boat trip. I only get to sample the highlights of any one timeslot and then on to the next segment. A hybrid live/virtual meeting offers both a “drift boat” and a ‘'wading” experience. During the meeting, each of us can hear live the things that we think are most interesting.

On Friday morning, Dr. Scott Smith from NASA will be speaking about the experience of microgravity and how it affects lymphatic physiology and our understanding of wound management and lymphatic disease. With our emphasis on data, we are dedicating a session to the Fundamentals of Research – giving our attendees the tools

to start generating data on their own. In addition to our dedicated abstract sessions, we will be having abstracts presented at other times and sessions to show everyone the data emerging from the Registry and other research projects. There will be sessions led by our colleagues from the AVF and the international VLM community, giving us the chance to see how things work in other settings. Returning to the river, it’s also critical to take a moment, stop fishing, and look around at the beauty of nature around us. Join us at the AVLS Taste of Colorado party on Saturday evening to see some of what Denver and the rest of Colorado have to offer and to support the Foundation for Venous & Lymphatic Disease through our Silent Auction. We are going to have a great few days together and a lifetime of learning to come. Enjoy the Meeting! Enjoy Denver!

STOP CMS’22 WHAT IS THE PROBLEM? Are you aware of the effect CMS Proposed Rules for 2022 will have on office-based specialty practices and your ability to serve venous & lymphatic patients? Nearly all venous & lymphatic codes will be cut by 20-24% due to a change in the Clinical Labor rate adjustments. These cuts are expected to result in the closing of many office-based specialties in vein care over the next few years, impacting patient access to care

WHAT IS THE AVLS RESPONSE? AVLS intends to fight the CMS Proposed Rules for 2022 with all administrative, legislative and legal options available from September – December 2021. To fight effectively, AVLS needs to address physician awareness on the CMS published position on venous and lymphatic disease while recruiting each physician it reaches to support the AVLS initiative, Stop CMS’22, with their volunteerism, advocacy and, most importantly, funding.

WHAT IS THE SOLUTION? AVLS is seeking two things from Stop CMS’22 Physician Advocates: 1.

Recruit & train a minimum of 300 Physician Advocates to educate CMS, legislators, other physicians and their Medicare patients about the CMS Proposed Rules for 2022 and the harmful effect these rules will have on venous and lymphatic medicine, including to restrict patient access, reduce patient’s seeking treatment, increase the financial burden on the healthcare system.

Solicit financial funding from each Physician Advocate at an average of $1,200 per donor, representing the average billable reimbursement from just one ablation per supporter.

HOW WILL THE STOP CMS’22 MONEY BE USED? All Stop CMS’22 donations received will be earmarked by AVLS for the Board to spend on advocacy initiatives to combat the adoption, implementation and codification of the CMS Proposed Rules for 2022 in the areas of venous and lymphatic medicine.

WHAT INITIATIVES DOES AVLS HAVE IN MIND TO STOP CMS’22? Fighting public policy is a process that involves many small fights and the ability to rapidly respond to such threats quickly to achieve a collective goal. Our initial goal is to prevent the

proposed CMS cuts for venous and lymphatic medicine from taking effect on January 1st, 2022, with the long-term purpose of preserving equitable venous and lymphatic code valuation and coverage for all eligible patients. Without a war chest to fund the rapid response needed or the ability to secure expertise or other data-driven resources, AVLS cannot advocate for its physician members. Those practices’ viability relies on public healthcare insurance coverages, and ultimately the treatment and care of venous and lymphatic patients serviced by them. AVLS has developed and begun implementing the following actions • Phase 1 - Study the CMS Proposed Rules for 2022 with all societal & community motivated organizations impacted by them - Complete • Phase 2 - Develop a direct response to CMS that addresses the identified concerns with the Proposed Rules to CMS formally by September 13th, 2021, hoping they will modify or suspend implementation of their proposed rules. In addition, we will develop support in Congress for the modification or delay of implementing of the Proposed Rule – Complete • Phase 3 - Prepare for a rapid response to CMS’s final decision on implementing their Proposed Rule expected for release in early November. AVLS and others will have a short window of opportunity to stop any negative impact on our specialty – In Process Each phase above will require projects, initiatives and contracting of resources not covered by the AVLS 2021 budget – so STOP CMS’22 is an extraordinary ask in response to an extraordinary act that will have a cataclysmic impact on venous and lymphatic patients and the professionals who treat them. AVLS is working to develop the economic impact on the specialty and the potential impact on patient access to specialty care in the office-based setting. • Baylor University Economics is studying the financial impact to the public healthcare system of the CMS Proposed Rules for 2022. The study models the effects on CMS expenditures using the assumption that patient care will shift from non-facility-based treatment (currently ~90% of all claims) to facility-based care. The financial impact of the proposed 20-22% venous revenue reductions effectively closes many practices (10% of current service sites). • Braid-Forbes Health Research study analyzes the financial impact of the Proposed Rule on highly weighted venous medicine practices. CMS estimates a negative impact of 6% for Vascular Surgeons on average and 8% for Interventional Radiologists as the proposed reductions for certain codes are balanced by gains with others within their 2022 projections. The AVLS research project looks exclusively at a venous disease-specific practice & the practice impact using the majority of typical codes reimbursed at the proposed 20-22% reduction in the CMS proposal. AVLS provided over 700 physician NPI’s for this analysis as to their actual Medicare claims impact. AVLS has also begun developing the legislative support in Congress to stop the implementation of the proposed rules • AVLS has founded and taken an Executive membership position with the United Specialists for Patient Access (USPA, www.uspaccess.org), a coalition of office-based specialties fighting to protect the payment structure of the Physician Fee Schedule led by Jason McKitrick and Liberty Partners, a contracted lobbying firm, targeting congressional education on the CMS Proposed Rules for 2022. AVLS has agreed to encourage large venous-related groups to also join the USPA effort. 10

• AVLS has developed and executed ongoing letter-writing campaigns directly to CMS for individual & influential organizations using print and digital submission options (www.myavls. org/cms22) for willing participants to express their concerns. • AVLS has developed and executed ongoing letter-writing campaigns directly to congressional leadership. Print and digital submission options (www.myavls.org/cms22) are available for participants to request their elected leadership to investigate the impact of the proposed CMS 2022 Proposed Rule on their constituents’ access to patient care.

PHASE 3 – IN DEVELOPMENT Depending on the final CMS ruling to be released in early November, we will potentially need to deploy aggressive tactics through Congress to prevent implementation. The response strategies are currently being explored by AVLS leadership and will be governed by the limitations of the funding developed by the STOP CMS’22 initiative. The number of donations made will dictate AVLS’s ability to advocate for its members’ interests, which will likely include exploring legal representation.

HOW DO I GET INVOLVED? The AVLS webpage, www.myavls.org/cms22, provides information on the STOP CMS’22 initiative and a list of all the action steps available for venous practitioners. In short, YOU can get involved by doing the simple three things below: • Inform – Be sure you are informed about how the Proposed Rule will directly impact your patients and practice and know about STOP CMS’22 & AVLS’s efforts being taken to protect your future. • Invest – Become an AVLS Physician Advocate and donate the encouraged amount of one typical ablation to the cause ($1,200). • Involve – Take up the cause and volunteer to contact your peers and engage them as Physician Advocates challenging them to donate to the cause and to contact their legislators. Engage your members of Congress and convey your concerns for the future of your patients. Inform your Medicare patients and ask them to contact their legislators. 22% is an extreme cut that will only reduce the number of patients being treated for their venous or lymphatic condition or pass the burden of their care off to a higher healthcare cost structure (hospitals). If we don’t take a stand – who will? Office-based venous care is a great value to the Medicare system, and caring for patients in the office setting benefits patients and the taxpayers who fund Medicare. The severity of the proposed cuts proves that. Stand and fight with AVLS and its Physician Advocates now!

By Dr. Sergio Gianesini University of Ferrara, ITALY

Uniformed Services University of Health Sciences, Bethesda, USA Connecting the Continent... Welcoming the World

American Vein & Lymphatic Society UIP Miami 2023 Congress Convener

The literal first aim of the International Union of Phlebology (UIP) is 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 and lymphatic disorders.” Following this vision, when I received the honor of being nominated Convener for the American Vein & Lymphatic Society (AVLS) UIP 2023 meeting candidacy, I immediately proposed to honor the same first aim by “connecting the continent to welcome the world” in Miami. I deeply thank AVLS for believing in this vision, immediately transforming it into a mission involving all of North America. The U.S., Mexican and Canadian scientific societies together are getting ready for what will remain a historic moment for global vein-lymphatic field advancement. The deepest gratitude goes to the American Venous Forum, the Canadian Society of Phlebology, and the Mexican Phlebo-Lymphology Academy for immediately joining our team on the project. This project mission will be accomplished by positioning a world-class scientific and educational meeting in beautiful Miami, Florida: one of the most charming international cities, readily accessible from all parts of the world. The nice climate and large venue will facilitate gatherings among vein-lymphatic experts from all around the world while guaranteeing proper safety measures. Both inside the scientific and social program and in a dedicated venue area, all the countries will enjoy equal opportunity to present their past, present, and future initiatives while being part of a single global team favored by the UIP organization. As UIP vice-president, I have had the chance to know this global organization in detail, appreciating its potential fundamental value of being a society of societies, a hub for all the organizations dedicated to vein-lymphatic advancement, a tool at the

disposal of the ones striving for improving local and global vein-lymphatic patient care. Over the years, having actively attended the many educational initiatives of all the North American societies involved in the UIP 2023 organization, I have had the opportunity to appreciate the top skills in phlebo-lymphology education delivery. Therefore, it’s clear to me how the synergy between the organizational expertise of the hosting societies and the global vision of the UIP will represent together an absolutely not-to-bemissed opportunity for national and international professional and personal growth. The availability of the many world-renowned key opinion leaders involved in the event will represent a further chance of full enjoyment of this special occasion. Particular attention will be dedicated to the new generations and the colleagues from countries with limited resources to facilitate veinlymphatic patient care improvement at all levels and regions. I look forward to gathering together in person in the beautiful Miami: a city chosen not only for its beauty but also for its geographical vicinity to Latin America. A perfect opportunity to “connect the North American continent, welcoming the world,” while building a bridge with South America. For those of you that have never visited Miami, you will find not only beautiful beaches and an exciting day and nightlife, but also easy access to a tremendous number of other tourism opportunities, such as the Florida Keys, the Everglades, water and land sports, together with vibrating cultural initiatives but to name a few. In conclusion, I hope you can join us. THANK YOU for joining not “just” the top scientific and educational mission and the pleasant journey, but mainly a vision that fosters moral and productive teamwork in North America, reaching out to the whole vein-lymphatic world.

UIP2023 Connecting the Continent... Welcoming the World

SAVE THE DATE SEPTEMBER 17 - 21, 2023 MIAMI BEACH, FLORIDA

ABVLM 2021 UPDATE

align with the end of the academic year. • ABVLM leadership is jointly working in a multi-specialty VLM Recognition Task Force with AVLS. This primary goals of this task force are:

By Dr. Neil Khilnani

On behalf of the staff and Board of the American Board of Venous and Lymphatic Medicine, I welcome you to Denver for the American Vein & Lymphatic Society's 2021 Annual Congress. We are all very excited about the prospects of being able to physically gather again as a community. I wanted to take this opportunity to bring Congress attendees and our Diplomates up to speed with what’s been happening at ABVLM over the last 12 months:

» Specialty recognition with the American Board of Medical Specialties and/or the American Osteopathic Association Board Certification, and » VLM training programs accreditation. • Active ABVLM accredited one-year Venous and Lymphatic Medicine Fellowships include: » Centers for Vein Restoration (several sites) • Program Director: Peter Pappas (Peter.Pappas@centerforvein.com) » Prisma Health System - Greenville, SC

• MOC Program Update: » The ABVLM Board is looking to add journal article-based self-assessments to the Online Learning & Assessment (OLA) program. The proposal we are considering is to push a journal article to our diplomates followed by questions for self-assessment. The selected articles will be recent review articles or original investigations with relevance to VLM. We are considering occasionally using this format as an alternative to the current “four items per month” self-assessment. We hope to trial this approach in the next calendar year. • CME credit for participation in the ABVLM MOC Program:

• Program Director: Marcus Stanbro (Marcus.Stanbro@prismahealth.org) » ProMedica / Jobst Vascular Institute Toledo, OH • Program Director: John Fish (John. FishMD@promedica.org) » Mass General / Harvard Medical School Boston, MA • Program Director: Julianne Stoughton (JStoughton@mgh.harvard.edu) • Please contact the Program Director if you are interested in exploring VLM training. • Please contact the ABVLM if you are interested in starting a one-year academic fellowship. • Additional information regarding VLM Fellowships is found at ABVLM.ORG.

» The ABVLM is investigating partnering with the AVLS to offer AMA PRA Category 1 CREDITTM (CME) credit for monthly MOC participation. We are hopeful to have this set up in the next calendar year as well.

For any questions related to ABVLM, feel free to reach out to me or Chris Freed, our Executive Director (freed@abvlm.org). We will be in Denver and Chris will be at the ABVLM Booth #417 in the Innovation Pavilion exhibit hall.

• ABVLM Certifying Exam dates: » In response to requests by recently graduated trainees, the ABVLM has permanently moved the certifying exam to August 1 - September 15 annually to better

We look forward to connecting with old and new colleagues, and for the exciting educational and social opportunities the meeting will offer. 14

Join the over 880 physicians who have already invested in their vein specialty certification

WINTER APPLICATION & 2022 EX AM DATES

Why Become Certified in Venous & Lymphatic Medicine? The benefits of ABVLM certification advance your career by helping you to: ELEVATE PROMOTE D EMO NSTR ATE FU LFI LL SU PPO RT

• • • • • • • • •

Elevates core knowledge in venous and lymphatic medicine (VLM) Promotes professional standards in VLM Demonstrates commitment to quality care of the VLM patient Ongoing, real-time, continuing education with an online MOC module Listed on the ABVLM “Find a Physician” website* Highlighted on the AVLS “Find a Provider” webpage as a Diplomate of the ABVLM* Fulfills a key AVLS requirement to obtain AVLS Fellow Status Supports venous credentialing in hospital or practice settings Demonstrates physician commitment to the field, which is critical to specialty recognition

*A single new patient will likely cover the cost of certification

2022 ABVLM Exam Schedule Annual Application Period November 1, 2021 to February 28, 2022 Exam Administration at PearsonVUE or remote OnVUE August 1, 2022 through September 15, 2022 Eligibility criteria for U.S. and Canadian physicians, and online application info, are at www.ABVLM.org. Passing the exam earns a 877-699-4114 info@ABVLM.org www.ABVLM.org 10-year certification. $500 Discount Code: 22VEIN

Patients trust certified education and experience

Spaceflight Research: The potential to improve wound care in our Clinics M. Mark Melin MD, FACS, RPVI, FACCWS

M Health Fairview, Wound Healing Institute, South Campus Adjunct Associate Professor, Department of Surgery, University of Minnesota Minneapolis, MN

Heather Hettrick PT, PhD, CWS, AWCC, CLT-LANA, CLWT, CORE Professor, Nova Southeastern University, Ft. Lauderdale, Florida

The American Vein & Lymphatic Society (AVLS) meeting in Denver brings an “elevated” component to the conference as a distinguished Wound Care Faculty discusses benchtop to clinical care and terra firma to Low Earth Orbit (LEO) topics aboard the weightless laboratory of the International Space Station (ISS). The session begins with an up-to-date data review of venous leg ulcer management, an intriguing discussion of the microcirculatory component of wound resolution and a deep dive into the endothelial glycocalyx: the historical perspective, glycocalyx recognition, the paradigm-shifting revision of the Starling Forces, and glycocalyx contribution to systemic health. The extensive and growing recognition of the functions of the glycocalyx, the revision and modification of the Starling principle forces, and paradigm shift in understanding that nearly 100% of interstitial fluid is returned to the central venous circulation by lymphatic pathways1 has contributed to a renaissance in lymphatic research and treatment options. The recognition that an intact glycocalyx imparts healthy microcirculatory function, while “thinning” and/or “shedding” of the glycocalyx is recognized as part of the disease process or aging, resulting in microcirculatory dysfunction. Shedding of the glycocalyx has been recognized in diabetes, arterial and

Frank Aviles Jr, PT, CWS, FACCWS, CLT-LANA, ALM, AWCC, DAPWCA

Wound Care Service Line Director, Natchitoches Regional Medical Center, Louisiana

venous hypertension, tobacco abuse, COVID-19 infection, pre-eclampsia, sepsis, and other states of acute and chronic inflammation2,3,4,5,6,7,8,9. Lymphatic contractility benchtop research will be reviewed, as will the lymphatic focus for improving wound care outcomes. Countermeasure management of venous and lymphatic dysfunction is highlighted by the impact of flavonoids, specifically hesperidin – diosmin, which has a long and bountiful history of benchtop and clinical trials in Europe. Emerging technologies in wound care and potential venous interventions will be discussed, with the morning session finale promising a robust discussion of astronaut health, adaptability to long-duration spaceflight, and reports on how environment and genetics impact astronaut health. The wound care session is an up-to-date, “Show Me the Data” session from some of the nation’s leaders in their fields. A unique evening event to capitalize upon the current interest in spaceflight and human physiology will be held at the Colorado Air and Space Port. The event will explore the data to date for venous and lymphatic alterations in function during the weightlessness of space travel. This area of research has a specific impact on astronauts during long-duration space missions, both in low-Earth orbit and planned missions to the moon and Mars. 16

Photos submitted by Scott Smith, Biomedical Research and Environmental Sciences Division, Human Health and Performance Directorate, NASA Johnson Space Center, Houston, TX

Spaceflight research and countermeasure development carry a high potential for “spinoffs” to improve treatment for patients in our own clinics. As the privatization of the space industry expands, these fields of research, in both Earth-based analogs and orbiting laboratories, will continue to grow and develop as the efforts for assuring nominal human function in “microgravity” and the weightlessness of space continue. Looking forward, the improvement of care in the extreme environment of space will require the brightest in both benchtop and clinical research. We are witnessing the dawn of a new era as private astronaut missions fly on sub-orbital trajectories, and private crews enter orbital flight and experience true astrodynamics. The first-ever private civilian four-person crew of Inspiration4, a SpaceX Dragon capsule, is led by experienced tactical jet pilot Jared Isaacman. His team includes a crew member who is thriving as a pediatric cancer survivor with a prosthetic bone. For three days, at an orbit higher than ISS, the crew will experience views of the cosmos that few can dream of, and only government-supported astronauts have experienced. They will also be exposed to the physiologic consequences of crossing the 100km high atmospheric-space boundary known as the Kármán line. Well above the Kármán line, in the weightlessness of space travel, humans and

spacecraft travel at 5 miles/second, witness 16 sunrises and sunsets every 24 hours, and normal human physiology adapts to the state of the constant free fall resulting in weightlessness while orbiting the Earth. In the absence of the normal “1G” hydrostatic gradient from head to chest, astronauts experience a dramatic redistribution of fluid from the legs to the torso, head and neck during the first 6-24 hours of spaceflight. Other physiologic changes include a reduction in plasma volume (10-17%), increased cardiac output and stroke volume (Doppler technique on ISS, 23-25% and 1921%, respectively), and a decreased systemic vascular resistance (14-39%). Additional spaceflight-related changes include the phenomenon of “neocytolysis,” resulting in the culling of young red blood cells (RBCs) and a relative decline in RBC total mass. Tissues undergo increased oxidative stresses, and increased inflammatory biomarkers reflect the potential to impact arterial function. Many astronauts experience ocular changes identified as Spaceflight Associated Neuroocular Syndrome (SANS), one of the top priorities for ground-based and spaceflight research. SANS has been suggested to occur because of “multiple hits;” cephalic fluid shifts and increased neck and facial venous diameters and pressures, a possible relative increased intracranial pressure, genetic differences (single nucleotide polymorphisms) resulting in B vitamin metabolism alterations, 17

and dysfunctional glymphatic pathways in both cerebral and ocular tissues. SANS countermeasure development may positively impact our patients with venous and lymphatic disease where environment and genetics impact healing rates and recidivism. Other cardiovascular and body system adaptations also occur, as astronauts exercise daily to battle these and bone and muscle deterioration10,11,12,13,14,15. Research on human adaptation to microgravity began with the first Mercury spaceflight in 1961 and continues on the ISS, a true weightless laboratory. The ISS has been continuously inhabited since 2000, currently supporting seven astronauts on 6-month expeditions. The ISS vehicle and its astronaut corps are supported by an extensive, diverse, international collaborative of women and men. While human research on ISS is expansive, with limited numbers of astronauts and constraints of research in microgravity, ground-based analogs are often utilized for simulating elements of space travel and human adaptation to flight. These analogs include 6° head-down tilt bed rest, dry immersion, undersea habitats, and aircraft, which can provide 20-30 second periods of weightlessness during parabolic flight16. Each can provide access to specific elements related to human adaptation to space travel and microgravity exposure. Human research in space has spanned the physiological systems of function: cardiovascular, neurovestibular, musculoskeletal, etc. One relatively new area of research is wound healing and closure in space, which will have greater importance given increasing crew autonomy of planned exploration class missions to the moon and Mars. This research carries the potential “spinoff” of improving how we treat patients in our 1G wound clinics.

WOUNDS IN WEIGHTLESSNESS A wound in space will be a defining moment and event as newly developed methods, and checklists will be used for medical management. Prevention of medical events is goal number one outside of low Earth orbit, as rescue missions or return to Earth-based care

may be virtually impossible. Telehealth and telecare from ground-based medical teams will be the best option, to whatever degree of communication delays on distant missions allow. During spaceflight, some astronauts experience rashes, hypersensitivity and atopic dermatitis, dermal changes that are potentially related to immune system dysregulation17. Cytokine expression and dysregulation have been researched in astronauts, demonstrating downregulation and altered growth factor release22. A pattern of novel cytokine alterations identified in astronaut saliva samples has recently been published19, demonstrating growth factors and cytokines associated with immune mobilization; significant increases in the plasma concentration of IL-3, IL-15, IL-12p40, IFN-a2, and IL-7, significant decreases in saliva GM-CSF, IL-12p70, IL-10 and IL-13, and increases in plasma TGFb1 and TGFb2 concentrations. This extensive new data adds to a complete characterization of space flight immune system dysregulation. Overall, the findings confirmed an in-vivo hormonal dysregulation of immunity that appears pro-inflammatory and persists during long-duration orbital spaceflight19. These types of chronic pro-inflammatory alterations and associated immune dysregulation may impact typical wound healing trajectory. Further research of cellular response to trauma, ischemia-reperfusion, and impact on wound healing will be needed in both groundbased simulations of weightlessness and true conditions of weightlessness in the space environment. Increased radiation exposure during space travel may also be a factor in wound healing as astronaut exposure to solar particle events and galactic cosmic rays will increase20, necessitating improved shielding for spacecraft and spacesuits. Endothelial cell function, nitric oxide production, and modulation of inflammation are processes recognized to be altered in “microgravity”21. Blood will float and form “domes” over wounds, impacting the normal pathways of hemostasis22. CO2 levels are higher in spacecraft than on Earth due to the resource constraints and the technical limits of 18

scrubbing it from the spacecraft’s atmosphere. A fractured bone of the lower extremity will be challenging to stabilize, not to mention that limb elevation in weightlessness is not possible to minimize edema in an astronaut experiencing fluid shifts. These environmental constraints in orbit and altered gravity environments of the Moon and Mars will add layers of complexity to wound and injury management. What will the space environment demand of wound care management in the altered gravity fields of the moon or Mars or the weightlessness of spacecraft? • Lightweight and small, given the mass and volume constraints of all spacecraft and associated costs to transport to orbit • Long shelf life, durable, reliable, no conditioned storage requirements (e.g., refrigeration), easy-to-maintain packaging, not bulky for storage • Does not break down with increased radiation exposure (i.e., Galactic Cosmic Radiation, which will be much higher in travel beyond low-Earth orbit and the van Allen Belt) • Easy to use by astronauts who may not have extensive medical training • Use of manageable liquids • Unique Hydrogels, poloxamers • Rapid tissue regenerative and restorative qualities with low recidivism rates • Provides an extensive replicative milieu of the tissue proteosome and matrisome make-up within the extracellular matrix • Antibacterial qualities Diet and nutritional status are known factors that can either enhance or delay wound healing. Food will obviously be flown (and likely grown) on all future space missions. Care needs to be taken to ensure nutrition is consistently used to optimize crew health23,24,25. High-quality nutrition, macro- and micronutrients, flavonoids, polyphenols, fiber, and clean replenishable fluids will be tantamount to systemic tissue and immune function to ensure maximizing

wound healing. Food will serve as a source of both refreshment and physical/psychological replenishment in an environment likely to be otherwise devoid of the normal comforts of Earth. The five main hazards of spaceflight and the space exposome are radiation, altered gravity fields, hostile and closed environments, and distance from Earth. Countermeasure research and development are now being conducted in analogs and on ISS26. In our wound clinics, we often discuss the environment, genetics and psychological barriers as either significant benefits or barriers to healing; the space environment will be the same as human physiology and adaptability are based on DNA. As single nucleotide polymorphisms (SNPs) become increasingly defined and understood within the genomic response to injury and pharmacogenomics, we will better understand how to decrease chronic states of inflammation (e.g., diabetes, vascular disease, metabolic syndrome, obesity) to improve response to chronic wounds and lymphedema and begin to deliver personalized, prescriptive, and precision care27. A new hope is on the horizon for vast improvements in care delivery through improved diagnostics and treatments as we enter 2022. Part of this hope will be derived from missions bringing the first woman and the first person of color to the lunar surface, from missions being contemplated to the red planet, and from missions closer to home with the privatization of the space industry. All of these will accelerate “spinoffs,” allowing all of us to join in these exciting national and international endeavors. While we know not what the future will grace us with for better serving our patients, we know that a better state of the art is always on the horizon, a pursuit we must continue throughout our time upon the Earth. We are in the era of “data,” and we applaud the AVLS leadership with their focus on data acquisition and application through research, presentations, educational support, open and transparent discussions, accountability, and fellowship at meetings. 19

We would like to thank Dr. Scott M. Smith, Biomedical Research and Environmental Sciences Division, Human Health and Performance Directorate, NASA Johnson Space Center, Houston, TX, for his thoughtful and insightful review and contribution to this editorial’s overall writing, nutritional and food components, and spaceflight elements.

REFERENCES 1.

Mortimer PS, Rockson SG. New developments in clinical aspects of lymphatic disease. : J Clin Invest. 2014;124(3):915–921. doi:10.1172/JCI71608.

Mitra R, et al. Glycocalyx in AtherosclerosisRelevant Endothelium Function and as a Therapeutic Target. Curr Atheroscler Rep (2017) 19: 63 https://doi.org/10.1007/s11883-017-0691-9.

Zolla V, et al. Aging-related anatomical and biochemical changes in lymphatic collectors impair lymph transport, fluid homeostasis, and pathogen clearance. Aging Cell (2015) pp1–13 Doi: 10.1111/acel.12330.

Zeng Y, Liu XH ,Tarbell J, Fu B. Sphingosine 1-phosphate induced synthesis of glycocalyx on endothelial cells. Experimental Cell Research 2015 Volume 339;1:90-9.

Goligorsky MS, Sunz D. Glycocalyx in Endotoxemia and Sepsis. (Am J Pathol 2020, 190: 791e798; https:// doi.org/10.1016/j. ajpath.2019.06.017.

10. Okada H, et al. Vascular endothelial injury

exacerbates coronavirus disease 2019: The role of endothelial glycocalyx protection. Microcirculation. 2020;00:e12654. https://doi. org/10.1111/micc.12654.

Weissgerber TL, et al. Early Onset Preeclampsia Is Associated With Glycocalyx Degradation and Reduced Microvascular Perfusion. J Am Heart Assoc. 2019;8:e010647. DOI: 10.1161/JAHA.118. 010647.

11. White RJ. Weightlessness and the human body. Scientific American September 1998; 59-63.

12. Norsk P. Adaptation of the cardiovascular

system to weightlessness: Surprises, paradoxes and implications for deep space missions. Acta Physiologica. 2020;228:e13434.

Castro-Ferreira R, et al. The Role of Endothelial Dysfunction and Inflammation in Chronic Venous Disease. Ann Vasc Surg 2018; 46: 380– 393 http://dx.doi.org/10.1016/j.avsg.2017.06.131.

13. Trudel G, et al. Characterizing the effect of

exposure to microgravity on anemia: more space is worse. Am J Hematol. 2020;95:267– 273.

Möckl L. The Emerging Role of the Mammalian Glycocalyx in Functional Membrane Organization and Immune System Regulation. Front. Cell Dev. Biol., 15 April 2020 | https://doi. org/10.3389/fcell.2020.00253.

14. Lee SMC, et al. Arterial structure and function during and after long-duration spaceflight. J Appl Physiol 2020;129: 108–123.

15. Lee AG, et al. Spaceflight associated neuro-

ocular syndrome (SANS) and the neuroophthalmologic effects of microgravity: a review and an update. npj Microgravity (2020) 6:7 ; https://doi.org/10.1038/s41526-020-0097-9.

16. Zwart SR, et al. Association of Genetics

22. Demontis GC, Germani MM, Caiani EG, et al.

and B Vitamin Status With the Magnitude of Optic Disc Edema During 30-Day Strict Head-Down Tilt Bed Rest. JAMA Ophthalmol. 2019;137(10):1195-1200. doi:10.1001/ jamaophthalmol.2019.3124.

Human pathophysiological adaptations to the space environment. Frontiers in Physiology 2017;8(547):1-17. Doi: 10.3389/fphys.2017.00547.

23. Farahani RM et al. Microgravity implications for wound healing. Int Wound J 2008;5:552-561.

17. Pandiarajan M, Hargens AR. Ground-

24. Douglas GD, Zwart SR, Smith SM. Space food

based analogs for spaceflight. Frontiers in Physiology 2020;11:article 716 doi:10.3389/ fphys.2020.00716.

for thought: Challenges and considerations for food and nutrition on exploration missions J Nutrition 2020;150(9):2242-4.

18. Crucian B, et al. Incidence of clinical symptoms

25. Smith SM, Zwart SR, Douglas GL, Heer M.

during long-duration orbital spaceflight. International Journal of General Medicine 2016:9 383–391. https://doi.org/10.2147/IJGM.S114188

Human Adaptation to Spaceflight: The Role of Food and Nutrition, 2nd edition (NP-2021-03003-JSC). Houston, TX: National Aeronautics and Space Administration Lyndon B. Johnson Space Center; 2021.

19. Immune System Dysregulation Onboard the

International Space Station. J Allergy Clin Immunol Pract (2016) 4:759–62.e8. doi: 10.1016/j. jaip.2015.12.021.

26. Smith SM, Zwart SR. Nutrition as Fuel for

Human Spaceflight. PHYSIOLOGY 36: 324–330, 2021. Published August 25, 2021; doi:10.1152/ physiol.00011.2021.

20. Krieger SS, Zwart SR, Mehta S, Wu H, Simpson RJ, Smith SM, Crucian B. Alterations in Saliva and Plasma Cytokine Concentrations During Long-Duration Spaceflight. Front. Immunol., 24 August 2021 | https://doi.org/10.3389/ fimmu.2021.725748.

27. Patel ZS, et al. Red risks for a journey to the red planet: The highest priority human health risks for a mission to Mars. npj Microgravity (2020) 6:33 ; https://doi.org/10.1038/s41526-02000124-6

21. Chancellor JC, Blue RS, 2 , Cengel KA, Serena

M. Auñón-Chancellor SM, et al. Limitations in predicting the space radiation health risk for exploration astronauts. npj Microgravity (2018) 4:8 ; doi:10.1038/s41526-018-0043-2.

28. Schmidt MA, et al. Why Personalized Medicine

Is the Frontier of Medicine and Performance for Humans in Space. NEW SPACE 2020; VOL. 8 NO. 2: 63-76. DOI: 10.1089/space.2019.0037

Photos submitted by Scott Smith, Biomedical Research and Environmental Sciences Division, Human Health and Performance Directorate, NASA Johnson Space Center, Houston, TX

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AVLS Fellows Give Back! By Dr. Marlin Schul

Over the past several years, the American Vein & Lymphatic Society (AVLS) has transformed its mission and vision to become the leading Society in the United States, advancing venous and lymphatic disease research with the PRO Venous Registry. To continue this vision, the Fellow Members of the AVLS have come together to develop a new research grant targeting young or new researchers in the field.

THE AREAS OF EMPHASIS FOR RESEARCH THAT THE GRANT WILL BE LOOKING TO SUPPORT • The science of compression therapy for chronic venous insufficiency, • Pathophysiology and/or Treatment of venous ulceration, • Diagnosis and Management of Superficial Disease. This new AVLS Fellows Grant will provide the scientific and financial resources to the recipient and, more importantly, provide a mentoring opportunity where a Fellow or Fellows will be available to advise and support throughout the execution of the research project. A Fellow Member of the AVLS is a member that has clearly demonstrated a level of experience and expertise in venous and lymphatic medicine who has also shown a commitment to advancing the Society and the field in general. Our Fellows are excited by the opportunity to support future researchers and leaders! The grant process will be somewhat unique from other grants that the AVLS has historically overseen. Three finalists will be selected from among the applicants and will be provided the opportunity to present their research proposals to the AVLS Fellows at the Annual Congress. The Fellows in attendance at the awards dinner will then select the recipient of the grant who will be announced during the Congress awards session, and their Fellow mentor(s) will be appointed. The winner will then have a year to complete their research, where they will then be required to present their results at the next AVLS Annual Congress. In addition to the support of a Fellow mentor, they will receive a $10,000 cash award, access to the PRO Venous Registry and data/analytical support from the Anyon Institute of Artificial Intelligence. Each finalist will receive a complimentary registration to the Annual Congress, two nights lodging at the Congress hotel and a travel stipend of $750. Currently, the AVLS Fellows are seeking a sponsoring organization interested in investing in the future of venous and lymphatic medicine. Applications for the AVLS Fellows grant will be accepted in the Spring of 2022, with the finalists being invited to the 36th AVLS Annual Congress to be held in New Orleans on October 13-16, 2022.

A RECENT PAPER EXAMINES ULTRASOUND-GUIDED FOAM SCLEROTHERAPY: WHAT IS THE CONSENSUS? WHERE IS MORE RESEARCH NEEDED? Todd V Cartee, MD, FAAD, FACMS, Associate Professor of Dermatology, Penn State Health Vineet Mishra, MD, FAAD, FACMS, Division of Mohs Surgery, Dermatology & Vascular Surgery, Scripps Clinic

Mixing a sclerosant agent with room air to create foam for vein occlusion or ablation has become a front-line therapeutic intervention for patients suffering from symptomatic chronic venous insufficiency. Yet, paradoxically, scientific literature regarding ultrasound-guided foam sclerotherapy (UGFS) remains very sparse in the United States clinical community and is only slightly better in Europe and the global venous community. In 2019, to better catalog the available literature and highlight current clinical practice in the United States, a small group of phlebologists began to examine existing papers and contemporary clinical practice regarding UGFS. In the July 2021 edition of the Journal of Vascular Surgery Venous and Lymphatic Disorders, the group’s work was published in their paper- Ultrasound-guided foam sclerotherapy is safe and effective in the management of superficial venous insufficiency of the lower extremity1. “When we started the project, I think what surprised us all was that even though UGFS is well-regarded by most clinicians, widely used, and has a good safety record, the literature was indeed uneven, and we need more high-quality comparative trials between UGFS and other modalities,” notes the paper’s lead author and Principal Investigator, Dr. Todd Cartee of Penn State University. In 2014, the American Vein & Lymphatic Society (AVLS), formerly the American College of Phlebology, published multi-organizational Quality Improvement Guidelines. The

guidelines were based on a questionnaire from practitioners at the AVLS Annual Congress. The 2014 guidelines were seminal, but surprisingly, no rigorous follow-up guidelines have been published since then by the venous community in the USA. “I think it’s fair to say that UGFS needs a new national guidelines project that we can all support, and we hope to use this paper to nudge AVLS and others to undertake such a project in the very near term,” added Dr. Cartee. “Our literature review revealed a large body of evidence demonstrating the safety and effectiveness of UGFS. UGFS is an excellent choice for managing numerous medium-sized varicosities for which phlebectomy would be time-consuming, for treating varicose veins that are not bulging on the surface but contributing to a patient’s symptoms, or in areas of advanced venous skin disease, which can make phlebectomy challenging.”

TWO KEY QUESTIONS FOR FOLLOW UP As the research team began their work, it became apparent that clinical practice had changed in recent years. When it comes to creating the sclerosant foam, “room air is still typical, but a sizable minority of practitioners now use gas, such as CO2,” commented paper co-investigator Dr. Vineet Mishra of the Scripps Clinic in California. This preference seems to be mostly based on the individual’s personal experience with UGFS and such issues as foam durability and size of bubbles. Though extremely rare, a few reported

examples of UGFS side effects have been reported, which may motivate some clinicians to use physiologic gas instead of room air since physiologic gas microbubbles are smaller and dissipate more rapidly. Second, the role that post-procedure compression plays in the treatment plan needs more rigorous study. “Wearing compression hose after UGFS is commonly recommended, but it would be ideal to have published data supporting how long the compression hose should be worn and at what compression level?” added Dr. Mishra.

COST-EFFECTIVE NATURE OF UGFS HAS PROMISE FOR ALTERNATIVE PAYMENT In the paper, the authors note that UGFS appears to have less long-term success than thermal modalities in treating truncal or larger varicosities, and retreatment may be needed. However, the inherent cost-effectiveness of

UGFS seems to give it an important place in the catalog of venous interventions. As Medicare and other payers continue to transition to alternative payment models or bundled payment, the capacity to treat chronic venous insufficiency with a low-cost option that achieves a predictable outcome becomes very attractive.

ULTRASOUND-GUIDED FOAM SCLEROTHERAPY IS SAFE AND EFFECTIVE IN THE MANAGEMENT OF SUPERFICIAL VENOUS INSUFFICIENCY OF THE LOWER EXTREMITY

Todd V. Cartee, MD, FAAD, FACMS; Paul Wirth, MD; Amrit Greene, MD; Chelsey Straight, MD; Daniel P. Friedmann, MD, FAAD; Chris Pittman, MD, FAVLS, FACR; Stephen F. Daugherty, MD, FACS, FAVLS; John Blebea, MD, MBA, FACS; Mark Meissner, MD; Marlin W. Schul, MD, RVT, FAVLS, DABVLM; Vineet Mishra, MD, FAAD, FACMS

Next-generation ultrasound systems Pictured: MX7 Ultrasound Machine

Visit Mindray at booth #519 to learn about our full portfolio of ultrasound solutions

Ideally suited for your vein practice 25

JOIN THE AMERICAN VEIN & LYMPHATIC SOCIETY AND SUPPORT:

ADVOCACY RESEARCH EDUCATION www.myavls.org/membership

LEARN SOMETHING NEW IN 2022 ONLINE EDUCATION

Explore the new AVLS eLibrary for on-demand education. Get an AVLS ePass for unlimited access to the entire catalog!

IMMERSIVE EDUCATION Transport yourself into the procedure room with our virtual reality courses, including a revamped Sclerotherapy Course and the new Introduction to Venous Insufficiency.

IN-PERSON EDUCATION Save the date for the return of in-person education with a full calendar of course offerings in 2022. LEARN MORE AT: www.myavls.org/education

2022 EDUCATION CALENDAR SCLEROTHERAPY COURSE April 9, 2022 Chicago, IL RPHS REVIEW + ULTRASOUND HANDS-ON April 9, 2022 Chicago, IL VENOUS & LYMPHATIC MEDICINE REVIEW COURSE April 10, 2022 Chicago, IL SCLEROTHERAPY COURSE June 10, 2022 Providence, RI RPHS REVIEW + ULTRASOUND HANDS-ON June 10, 2022 Providence, RI NON-THERMAL TREATMENTS June 11, 2022 Providence, RI CLT-LANA REVIEW COURSE June 11, 2022 Providence, RI AVLS 36TH ANNUAL CONGRESS October 13-16, 2022 New Orleans, LA UIP WORLD CONGRESS + AVLS 37TH ANNUAL CONGRESS September 17-21, 2023 Miami Beach, FL

Can you recognize Lipedema in your patients and research studies? Lipedema may be influencing: • Microvasculature, including spider and varicose veins, and a tendency to bruise • Reduced blood pressure • Swelling in the legs

Learn more about the research we fund: lipedema.org/research-impact

THE KING IS DEAD, LONG LIVE THE KING

3. AVLS Immersive Education – Experience new

courses utilizing virtual reality technology that enables the learner to be transported into a clinical setting where they can observe procedures as if they were standing right next to the instructor. These courses provide clinical education and training without sending your team to various locations for in-person training. AVLS is introducing two new courses at Annual Congress, Sclerotherapy 2nd Edition and Introduction to Venous Insufficiency, which interchange virtual reality with two-dimensional didactic lectures. A series of additional courses are in development for future release, including thermal ablation, Varithena, Venaseal and pelvic venous procedures, including IVUS.

By Steve Elias, MD, FACS, FAVLS, DABVLM

This seemingly nonsensical, contradictory phrase has been uttered since 1422 when the French king Charles VI died, and his son Charles VII took over. Le roi est mort, vive le roi. The words were spoken by the Duc d’Uzes as soon as Charles VI’s coffin was lowered into the ground. The phrase actually makes complete sense. It succinctly summarizes the transfer of sovereignty. One king is dead, another has taken his place, and long live the new one. Old and new flow seamlessly for the good of all. That’s what AVLS has been doing for years regarding education and learning, always moving forward. The old style of only in-person education is dead but long live the new AVLS style: in-person and digital/remote. So, what does the new “king” offer? 1. AVLS Annual Congress – On-Demand: Congress is now a hybrid event where every session is recorded and made available to all registered attendees “on-demand” for a couple of months, enabling attendees never to miss a lecture or session. It also expands the available CME from the typical 21-23 hours to over 60 hours.

2. AVLS ePass – A new subscription service that

offers access to the digital library of AVLS educational programs. With a subscription, the individual can access the library and partake in as many or as few courses as desired. This resource is excellent for training new staff, nurses, PA’s, etc., where you can have them access a list of courses you require for your practice. Subscriptions will be offered on a monthly and annual basis.

4. AVLS Presents – A series of webinars will be presented each month, focusing on specific educational or training topics in venous and lymphatic medicine.

5. AVLS Venous Classification Workbooks –

The AVLS, in conjunction with the AVF, have developed two workbooks that help learners apply the venous classification systems for both lower leg (CEAP) and pelvic venous disease (SVP). Both workbooks take you through a series of case presentations where the learner is asked to classify each patient.

Even though there are many digital/remote offerings, AVLS is not proposing that inperson learning is dead. Unlike the attitude of France towards Charles VI, AVLS doesn’t only recognize the new king. There is so much value to in-person, in-the-flesh, I’m really alive learning: spontaneous peer-to-peer discussion, post-lecture hallway questions and answers, having a drink together, etc. AVLS offers the best of both worlds. COVID-19 has just accelerated an inevitable event. Because of this, AVLS learning and educational opportunities are better than ever. AVLS is not dead. Education is not dead. Vive le AVLS, vive l’education. Take advantage of everything. Learn the best way for you. Bonne chance (Good luck).

Phlebectomy Zones in the Lower Extremity AVLS members Dr. John Blebea and Dr. Ken Harper are conducting research utilizing the AVLS PRO Venous Registry. They hypothesize that the majority of phlebectomy sites are located within four zones of the leg. It has been suggested that reimbursement for phlebectomy procedures would be better based on anatomic location rather than the number of phlebectomies performed. The distribution of potential anatomic zones on the leg proposed varies from 3 to 32. Although more zones would provide greater specificity, fewer zones would be easier to define and more likely to be employed by physicians. The most recent Registry update provides 14 anatomic zone locations, which would provide, for the first time, real data on actual phlebectomy sites in clinical treatment.

Upper Thigh - Medial

8. Upper Calf - Medial

2. Upper Thigh - Anterior - Lateral

9. Upper Calf - Anterior - Lateral

3. Upper Thigh - Posterior

10. Upper Calf - Posterior

4. Lower Thigh - Medial

11. Lower Calf - Medial

5. Lower Thigh - Anterior - Lateral

12. Lower Calf - Anterior - Lateral

6. Lower Thigh - Posterior

13. Lower Calf - Posterior

14. Foot

Knee

Because providers do not currently capture these zones in their respective EMRs, AVLS has developed an app that can be used to collect data and contribute to this study. We encourage our members to participate in the AVLS PRO Venous Registry and submit their phlebectomy data through this application. For more information, please stop by the AVLS booth in the New Horizon Plaza.

REPORTING FROM THE AVLS PRO VENOUS REGISTRY By Dr. Robert Worthington-Kirsch

ne of the pillars of the AVLS is our commitment to science and research in venous and lymphatic medicine. The membership supports research through several projects, including the PRO Venous Registry, by providing grants for clinical trials. The AVLS Fellows Grant encourages younger members to get involved in research activities, publish cutting-edge research in Phlebology, and present research at our Annual Congress.

projects from the Registry, including a general overview of patient symptom severity before and after treatment of superficial venous insufficiency, an overview of current practice patterns in phlebectomy, a comparison of post-procedure complication rates after radiofrequency ablation to those after endovenous adhesive ablation, variations in disease presentation and treatment between rural and urban communities, and several studies about the utilization and complication risks of truncal ablation using proprietary This year the theme of the endovenous microfoam. Annual Congress is “Show Some of these studies are Me the Data.” Research in designed to answer specific our area is maturing with questions that some of more and higher-quality studies presented each year. our industry sponsors have posed. Additionally, This year is also the first time several working groups our teams of investigators will be reporting out studies designed studies to based on data from the PRO hopefully answer questions Registry at Annual Congress. important to the entire community of those working Teams from within the AVLS in venous and lymphatic are working on preparing medicine. abstracts on a number of 32

We want to encourage you, the reader, to partner with us by becoming a data contributor to the Registry. The more data we receive and the wider the range of practices from which we receive that data, the better our science is. We will get stronger evidence to support evolving guidelines and clinical resources. This translates into better patient care, better outcomes for our patients, and better establishment of the validity of the care we provide in the eyes of other entities with interest in our practices. In addition to providing data, data contributors have the opportunity to join our research teams and task forces. This allows them to have input into the development of study topics, the execution of these studies, and opportunities for presentation at meetings and authorship in the literature.

Understanding and Applying Venous Classification Systems By Joyce King The goal with these workbooks is to create an interactive, online learning experience allowing physicians to walk through and study the CEAP and SVP classification systems on their own time. Plus, apply what they learned through completing case studies.

With the publication of the SVP venous classification system for pelvic veins comes the challenge of learning how to use the new system. The AVLS Education Committee and American Venous Forum (AVF) created the Venous Classification Workbooks for CEAP and SVP to help practically educate and apply classifications in venous practices.

Additionally, the AVLS is releasing the SVP Classification App to go alongside the SVP workbook and into practices to assist with using the SVP Classification system in every day patient encounters.

Instead of listening to a series of lectures and trying to apply the venous classification systems without guidance, the workbooks walk through not only what the system means but how to use it to improve your practice.

Appropriately applying venous classification systems is significant for future research and advocacy around venous disease.

After reviewing the research and support for the CEAP or SVP classifications, the digital workbooks walk through a series of case studies. Each case study is interactive, providing the learner the opportunity to classify the case themselves and correcting their classification when needed.

The workbooks will be launched in Fall of 2021 and available as individual CEAP or SVP workbooks or as a bundle. The AVLS and AVF will be offering these for sale on their websites with special member pricing. Learn more by connecting either online or in-person at the AVLS Annual Congress.

Once all the case studies are completed, the course offers a certificate for those who achieved an 80% pass rate and the opportunity for further education for those who did not.

C O R P O R AT E Thank you to our

INDIVIDUAL New Horizon Donors! forMel CHAIRMAN James D. Albert Dean Bender Felicite Daftuar Terri Harper Sanjiv Lakhanpal Brad Moseley The Mel Rosenblatt Family

DIAMOND Scot J. Dube Gordon Gibbs Eric Heil Joseph T. Jenkins Lowell Kabnick Chris Pittman A. J. Riviezzo Marlin W. Schul

RUBY Aditya Gupta Jeffery P. Schoonover Sean Stewart Satish Vayuvegula

EMERALD Glenn Anderson Paul H. Cheatum Michael Di Iorio Steve M. Elias Liza Eden Giammaria Joseph T. Jenkins Joseph A. Zygmunt, Jr.

GOLD

DONOR

Cynthia B. Asbjornsen Joseph Ty Bell Catherine Burdge Yung-Wei Chi Alan P. Crowther Stephen F. Daugherty Mark D. Forrestal Kathleen Gibson Margaret Mann Vineet Mishra Diana L. Neuhardt Kenneth L. Todd, III Robert Worthington-Kirsch

Michael Aikens Lisa Amatangelo Luis Barajas Michael Cornwell Stephanie Dentoni Lance Dillon Suzie Ehmann Chris Freed Mark Joseph Garcia Amanda Godwin Aditya Gupta Todd Hansen Mohamed Hassan Marresa Houle Fernando Illescas Laura Kelsey Seema Kumar Duc Le Thomas Leaton William Marston Mark Meissner Khanh Nguyen Michelle Nguyen Bonnie Pauza-Miller Chris Pittman Neal Reynolds Anuj Shah LouAnn Smith Lawrence Starin Sonja Stiller-Martin Ronald Winokur Steven Zimmet

SILVER Thomas Alosco John Blebea Jeff Braxton Anthony Comerota Zoe Deol David Draughn Sergio Gianesini Michael Graves Evan Harris Lowell Kabnick Neil M. Khilnani Terrance Krysinski Daniel Monahan Nick Morrison Tyler Palmer Betty Sanchez Saundra S. Spruiell Julianne Stoughton Dominic Tolitano Darren Wennen Thomas F. Wright

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For more than 18 years, Total Vein® has satisfied the rigorous cost and quality demands of vein surgeons nationwide. Call on our team for unparalleled service, a full range of products and the lowest supply-cost-per-procedure in the industry!

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